Inspection on 03/04/07 for 5 Wellington Street

This inspection was carried out on 3rd April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 Wellington Street 26/01/06

5 Wellington Street 17/06/05

5 Wellington Street 11/11/04

5 Wellington Street 07/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 5 Wellington Street West Bromwich West Midlands B71 1DR Lead Inspector Jayne Fisher Key Unannounced Inspection 3rd April 2007 08:50 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 5 Wellington Street Address West Bromwich West Midlands B71 1DR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 532 3558 NONE Pioneer Care Limited Ms Sandra Horsley Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26th January 2006 Brief Description of the Service: 5 Wellington Street is a semi-detached property which is rented from the Local Authority by Pioneer Care Limited and is located in West Bromwich. The centre of town is within a two-mile radius and there are local shops nearby. Public transport is good. The Home provides care for three service users with learning disabilities. All service users are fully mobile. The accommodation includes: a lounge/dining room, kitchen and toilet. There are four bedrooms one on the ground floor, three on the first floor, one of which is used as an office/sleeping in room for staff. There is a domestic type bath and toilet. There is a quiet/activities room located on the first floor. There is a patio and large lawned garden to the rear of the property. This garden is well established and secluded. All of the service users attend local authority run day centres during the week, however staff are always on duty during the daytime in case a service user does not wish to attend day care or is unwell. The Home provides a range of activities for residents to undertake in their leisure time as well as an annual holiday. A statement of purpose and service user guide are available to inform residents of their entitlements. Information regarding the fee level was provided on by the provider in February 2007 which is £741.68 per week. There are additional charges for toiletries and hairdressing. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first key inspection for the period 2006 – 2007. As it was a key inspection this means that all core National Minimum Standards were assessed. This inspection was unannounced meaning that no one received prior notification. The inspection started at 8.50 a.m. and finished at 4.20 p.m. In order to measure the homes performance a range of methods were used. Information was gathered and evaluated prior to the visit. Interviews were held with the registered manager, acting manager and two members of staff. Two comments cards were completed by relatives. There are three residents living at the home. They were issued with comment cards but would not have been able to fill them in without assistance from staff. The feedback cards were therefore not completed. The inspector interviewed a resident who was at home during the day time, and also saw and spoke with two residents upon their return from their day centres. Observations were made of interaction between staff and residents through out the day. A number of records and documents were examined, a tour of the premises was undertaken and a meal time was observed. What the service does well: What has improved since the last inspection? Management and staff continue to work towards making improvements which are identified during inspections. Since the last visit these have included ensuring that care plans are reviewed on a regular basis with residents so that they are kept up to date. Assessments have been undertaken to evaluate whether residents need extra nutritional support and there are now regular checks of food temperatures. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 6 A refurbishment programme is currently in the process of being undertaken and this has included the installation of a shower so that residents can have a choice of bathing facility. This will include redecoration of residents’ bedrooms. There is more regular formal supervision of staff and an annual appraisal system has been introduced to assist management with ensuring that staff are able to meet the needs of the residents. Very good progress is being made towards introducing a quality assurance system which allows residents to participate in the development and shaping of their service. This demonstrates that residents are listened to and that their views are important. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. There is an holistic assessment process so that new and existing residents can be assured their individual needs will be measured and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has no vacancies and has remained fully occupied since 2003. Observations and interviews confirm that the last resident to be admitted is happy and settled at the home demonstrating that management operate a successful admission procedure. On examination residents’ case files contain an holistic assessment of need which are reviewed on a regular basis as required by the Care Homes Regulations 2001 and in order to ensure that service provided continues to meet individual needs. There is an outstanding requirement to expand residents’ terms and conditions of occupancy to ensure that these contain all of the elements identified by the National Minimum Standards 5.2. On examination these documents now contain the exact fee level and are signed by the registered manager and service user (and/or advocate). However, as discussed with management these documents must also contain details of additional charges which are not contained as part of the basic contract fee. This information must also be 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 9 included in the service user guide. For example, residents pay for their own toiletries, hairdressing, newspapers and magazines. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. Care plans and risk assessments provide staff with important information necessary to support residents. Residents are actively encouraged to participate in the planning and delivery of their care and are able to exercise control over their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On examination care plans cover a wide range of needs and contain comprehensive and very detailed information regarding the resident. These have been recently reviewed and updated by the registered manager and staff team. There was evidence that relatives were invited to attend the six monthly review meeting to participate along with the resident in the review and planning of their care. The registered manager stated that social workers also carry out an annual review and copies of minutes were seen. Care plans have been reproduced in pictorial formats for residents and they include a 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 11 person centred approach with details of residents’ preferences, likes and dislikes. Residents are able to have ready access to their care plans and during interviews one resident stated that she enjoyed looking at her care plan folder and was observed to routinely fetch the care plan through out the day and look through it. There are detailed communication packages in residents’ case files. Residents are encouraged to make decisions about their lives through person centred planning, quality assurance mechanisms and in addition there are regular meetings held which are fully minuted. There are detailed guidelines contained within residents care plans regarding how they are supported to manage their finances and their consent has also been obtained to allow staff to help them in this area. There is a comprehensive and complex risk management system in place. During interviews staff and management demonstrated a good knowledge of how the system operates and there is an explanatory scoring system contained within the case file. All risks are evaluated and if there is a significant risk identified, a detailed risk assessment action and plan sheet is completed. On examination there were a wide range of risks assessed and evaluated. There was only one minor issue identified during inspection of these standards which needs action. During interviews the acting manager stated that one resident requires some support by staff when getting in and out of the bath. There is no lifting involved and apart from this, the resident has good mobility There was no care plan or risk assessment in place regarding this resident’s mobility and the support provided by staff for her to access the bath. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. Residents are supported to lead meaningful and stimulating lifestyles and have regular access to the local community. Staff help residents to maintain important links with their relatives. Residents are offered a varied and healthy diet which they help choose, shop and plan. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents attend varying forms of day centres and colleges through out the week. During interviews one resident said “I like my college; I like living here”. On the evening of the inspection, one resident returned with a load of vegetables which he had helped grow and excitedly showed these to staff. Activity planners are in place and there is a daily diary system in which staff record activities undertaken. Examination of the very detailed entries completed by staff in residents’ diaries confirmed that they enjoy a range of 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 13 stimulating activities and community outings and regularly go to church. The activity planners are not rigidly followed and upon discussion management stated that this is because activities are service user led and won’t occur if the resident chooses to do something else. Managers stated that they were confident that residents would express their dissatisfaction if they were not allowed to do what they wanted. As observed, residents can clearly communicate their needs and preferences and did so through out the day. The resident who did not attend her day centre, made her own choices regarding the range of activities offered by staff. For example she was seen to choose to help with making drinks, preparing lunch, chatting to staff and doings arts and crafts. During interviews she stated “I like going to the pub” and confirmed that she went shopping with staff to the supermarket each week. Interviews with a resident confirmed that she had regular contact with her family. Daily diaries also demonstrated that relatives have regular visits, maintain telephone contact and take their family members out on trips. Both relatives who completed comment cards stated that staff helped residents to keep in touch. One person stated “yes my sister phones me to have a chat regularly”. Daily routines were seen to be flexible. Residents were seen to be able to choose when to go to their own bedrooms and had unrestricted movement around the home. Case files contained confirmation that residents gave consent for staff to open their mail. Residents do not have keys to their bedrooms as locks are not suitable (see further comment in standard 24). Through out the day all staff were seen to interact positively with residents; residents were greeted warmly by staff upon their return from day centres. They looked happy and excited to be back at their home. Appropriate caring support was given to one resident who was upset due to an incident which had occurred on the minibus. Both relatives who completed comment cards stated that they felt residents were supported to live the life they choose. There is no set menu plan. Instead, residents choose on a daily basis what they would like to eat which is reflective of the principles of ordinary living. Staff and residents confirmed that they help choose and shop for their own food. Food records were not always consistently completed by staff, however they demonstrated that residents can choose different meals. They also demonstrated a healthy and varied diet with lots of meat, vegetables, fish and pasta. Fridges, freezers and cupboards were well stocked. A lunch time meal was observed. The resident was seen to enjoy her meal which staff had taken the time to ensure was well presented and varied. Since the last visit nutritional screening tools have been updated as previously required. It is recommended that more holistic screening tools are considered which include calculating people’s ideal weight using the body mass index (BMI) scoring system. Details were supplied to management regarding how to access such tools. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. Staff provide sensitive and flexible personal support to residents and ensure that any health care needs are quickly identified. There are generally safe systems in place for residents with regard to medication although these could be enhanced slightly further. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ preferences as to how they are guided and supported are contained within their care plans and person centred plans. These include references to whether they would like male or female staff to support them. The registered manager explained that residents’ choices would only be overridden if their was a safety issue identified. Both relatives who completed comment cards stated that they felt the home met the needs of their family member. Statements included “Yes my sister is happy and well looked after. She gets on well with everyone in the home”. “Carers support service users as individuals; allows choices”. Interviews with staff and case tracking demonstrate that there are very good systems in place for ensuring residents’ health care needs are met. For 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 15 example, there are extremely useful ‘health care appointment’ sheets in place which list the appointments through out the year. In addition there are separate report sheets which record the outcomes of the appointments and any treatments. If there is a particular health care need; then a separate care plan is generated. There are care plans in place with regard to screening for breast and testicular cancer. Residents have ‘health action plans’ which have been completed by the community learning disability nurse. They also have access to dentists, ophthalmologists, chiropodists, psychiatrists and receive an annual health check. There is only one area which requires improvement. The acting manager states that residents are supposed to be weighed monthly. Weights are recorded in the residents’ individual daily diaries. Upon checking, the acting manager could not locate any weight checks for February 2007. It was found through case tracking that one resident had gained 7 lb in four months but this had not been noted by staff, and the care plan contained no details of what further observations or monitoring was needed (or if none was required, why this was unnecessary). The registered manager and acting manager agreed that an improved monitoring system would be beneficial. Since the last inspection the registered manager confirms that the medication policy has been updated and staff have signed this document as previously requested. The registered manager reported that good progress is being made towards ensuring that staff have received accredited training in the safe handling of medication. Where staff have not yet completed this training they undertake a ‘medication management’ course in the interim. There was a certificate in place to evidence that a new member of staff had received this ‘interim’ training. On the whole there are good systems in place for managing residents’ medication but some improvements are necessary. For example, keys to the drug cupboard still need to be held separately as previously required. The drugs cabinet needs to be secured to the wall. There are computerized medication administration record (MAR) sheets. On occasion staff have to enter handwritten instructions onto the sheets. As discussed with the acting manager, two staff initials must be obtained to confirm that they have witnessed and agree that the correct instructions have been transcribed onto the sheet. Two staff initials are entered onto MAR sheets to identify that they have checked and receipted medication coming into the home but as discussed with the manager, they are failing to record the actual date of receipt which led to some slight confusion regarding one medicine. There are guidelines in place for the administration of ‘as and when required’ (PRN) medication. It is recommended that these are expanded to exclude the maximum days the dosage can be given before seeking medical advice. The registered manager agreed to put this in place. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. There is a comprehensive complaints system which ensures that residents’ views are listened to and acted upon. There are sufficient systems in place to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection the home was seen to have a comprehensive complaints procedure with timescales which exceeds the national minimum standards, and details of the Commission for Social Care Inspection (CSCI). There is also a complaints procedure which has been produced in pictorial format. The Home has included the complaints procedure in the statement of purpose/service user guide as required. There have been no complaints made regarding the service during the last year. Comments from relatives who completed feedback questionnaires confirmed that they are aware of how to access complaints. It was suggested to the management that complaints, and how to raise concerns could be made a topic for discussion at forthcoming residents’ meetings. During interviews staff and management gave appropriate responses as to how they would deal with any potential incidents of abuse. A copy of the Local Authority vulnerable adult abuse procedures were available on the premises for staff to reference if required. A pictorial vulnerable adult abuse procedure has also been produced for residents which is an excellent initiative. There has been an outstanding requirement for the provider to update their own 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 17 vulnerable adult abuse policy to include Protection of Vulnerable Adult (POVA) guidelines. This policy was sent to the Commission following the field work visit and contained reference to the POVA guidelines. There is good progress towards ensuring that all staff have received training in vulnerable adult abuse. Of the two staff files examined one contained a certificate, the other member of staff was said to have undertaken this training and was awaiting a certificate. All service users have appointees to oversee management of their finances; these are either the Local Authority or a family member. There are regular audits undertaken of monies and records by a senior manager from the organisation and daily checks of balances by staff. Double signatures from either staff or residents are now obtained for all transactions. Two residents’ personal expenditure sheets were checked and balanced accurately with monies held. Only a couple of anomalies were identified. Staff usually record the type of transaction undertaken on the personal expenditure sheet however on one occasion dated 23 March 2007 this had been left blank. Upon checking the till receipt for the items purchased this was dated 1.23.07 which had not been identified by staff (or corrected). The corresponding petty cash voucher stated that a meal of fish and chips was purchased which did not correlate with the till receipt. Upon further discussion with management it was ascertained that the resident had been inadvertently charged for the meal when out in the community and had not been reimbursed (this was in place of a meal normally provided by the home). The registered manager agreed to ensure that the resident was suitably recompensed. Residents do not have access to bank accounts. Although their savings are held by their appointees, it is recommended that their personal allowances and other benefits could be held in bank accounts. These can then accrue interest and at the same time encourages independence. The registered manager stated that she had already identified this as an issue for one of the residents, and agreed to pursue this for the remaining two people. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. Residents live in a comfortable and attractive home. The premises is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was undertaken and one resident showed the inspector her bedroom. During interviews she stated “yes I like my bedroom”. The landlord is currently carrying out a programme of refurbishment including replacement of the kitchen, installation of a new bathroom and shower, rewiring and replacement of radiators. A requirement to ensure that there is access to thermostatic controls on radiators has been withdrawn. The house was extremely clean and tidy through out. A new settee and armchairs were delivered during the visit. The registered manager stated that residents’ bedrooms are also to be redecorated. These were seen to contain lots of residents’ own personal possessions and felt very homely. There has been an 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 19 outstanding requirement to install suitable bedroom locks. These have been changed so that there is a thumb turn over ride mechanism on the inside however they cannot be locked with a key when vacated by the resident. The registered manager agreed to look into this as it was confirmed that residents would be able to hold and use a key. There are also a couple of remaining requirements still outstanding as identified in the Requirements section of this report. Apart from a lack of supply of liquid soap in the toilet and first floor bathroom, and a mop stored in the kitchen area, infection control measures were seen to be adequate. One relative commented that “the house is always clean and tidy”. The registered manager asked for advice regarding the new pet cat and feeding area. It was suggested that a risk assessment be carried out and kitchen cleaning schedules updated to include regular cleaning tasks around the feeding area. Further advice can also be sought from Environmental Services. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. Residents are supported by a skilled and competent staff team who know their likes and dislikes. Recruitment and selection procedures generally offer suitable protection to residents although record keeping needs slight improvement. Good progress is being made in ensuring staff have specialist and vocational training in order to meet all residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Interviews and observations made during the fieldwork visit confirms that staff are aware of residents’ needs and preferred routines. Relatives made positive comments regarding staff including “they do a really good job, they are very caring and helpful”. Good progress is being made towards providing staff with vocational training and during interviews staff confirmed that they were undertaking this training. At present two of the eight support staff employed have fully completed an NVQ II or above. A sample of training certificates and training records were examined which indicated a range of statutory and specialist training is taking place. Unfortunately, some training certificates are still awaited and as discussed with the registered manager, once these are 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 21 available for inspection the outstanding requirements will be deemed to have been met. The duty rota was examined and confirmed that there has been no reduction in staffing levels. There are two staff on duty at peak times during the day. The hours worked by the registered manager have not been included on the rota and neither have the hours worked by the acting manager. There are regular and well minuted staff meetings. A personal file of a new member of staff was examined in order to evaluate recruitment and selection procedures. This could not be fully undertaken as some records were not available for inspection. For example, the application form was still held at the organisation’s head office therefore it was not possible to identify whether any gaps in employment had been explored, or whether or not there was a full employment history obtained from the applicant. There were two written references available but one of the referees did not give the dates of employment. There was also a statement from the referee which needed further discussion, but the registered manager had been unable to discover whether this had been carried by the human resources manager. A health declaration had been signed by the applicant but was not dated. There was no photograph on the file although there were copies of identification and an up to date criminal record bureau (CRB) disclosure check. The registered manager agreed to investigate the anomalies identified and to forward copies of the missing information to the Commission on the following day. This was duly undertaken and suitable information provided to demonstrate that a senior manager had contacted the referee to discuss the issue raised, although there was no confirmation obtained of the dates of employment. The registered manager agreed that further information was required regarding the gap in employment which needed verification. It is pleasing to see that staff and residents are involved in the recruitment and selection process. Two staff files examined contained copies of terms and conditions of employment as previously required. Staff who were interviewed confirmed that they had undertaken induction and foundation training provided by an accredited learning disability awards framework (LDAF) provider. There were also copies of in-house induction programmes contained within staff files. Staff were said to have recently undertaken training in equal opportunities and disability equality although both staff files examined did not contain training certificates which were said to be awaited. There is a central staff training and development plan in place but as discussed with the acting manager, dates need to be inserted to identify when training planned has taken place in order to give an accurate picture of the training needs of the staff team. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 22 Since the last inspection improvements have been made with regard to introducing an annual appraisal system and increasing the frequency of supervision sessions. Both staff files examined contained an annual appraisal and two supervision sessions had taken place since 1 January 2007. There were detailed records completed by management of discussions with staff although it is recommended that work with individual service users is also discussed and recorded during these forums. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. The registered manager is supported well by her senior staff in providing clear leadership through out the home with all staff demonstrating an awareness of their roles and responsibilities thereby protecting service users’ health, safety and welfare, with only slight improvement necessary. This judgement has been made using available evidence including a visit to this service. EVIDENCE: For some time there have been plans to replace the existing registered manager, who currently has responsibility for a number of other services owned by the provider. The registered manager reports that this is still the intention, but at present there is an acting manager in place who is covering for another acting manager, who is currently on maternity leave. The registered manager still has legal responsibility for the home, visits on a 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 24 regular basis and is actively involved in the management of the home. Findings from this inspection indicate that the management arrangements continue to work effectively. Managers undertake regular meetings with staff, residents and there were positive comments made by relatives. In addition staff receive regular supervision, guidance and direction. Any problems with practices are swiftly and proactively dealt with by management. Managers were observed to have a very good rapport with residents. The registered manager stated that she has now obtained her registered manager’s award and is currently completing an NVQ IV in care. During interviews Mrs. Horsley demonstrated that she was knowledgeable and keeps up to date with changing legislation. It is recommended that the home is enabled to access and use email and web site facilities to assist with communication and researching current good practice and guidance. Appropriate facilities for communication by facsimile transmission should also be provided. Interviews with the registered manager and documentation supplied confirms that very good progress is being made in introducing a comprehensive and all encompassing quality assurance system. Great efforts have been made to consult with relatives, stakeholders and staff. Residents have participated in this process and have been assisted by residents from another home which is an excellent initiative. An analysis has been carried out and the registered manager is currently in the process of establishing a suitable format for presenting the findings. The registered manager confirms that once this process is completed, an annual development plan will be created. Generally health and safety is appropriately managed at the home. Information supplied to the Commission prior to the inspection confirms that a range of maintenance and service checks are in place which were validated on examination of relevant records. For example, there is weekly testing of smoke alarms and daily testing of water temperatures. There is a fixed electrical wiring certificate in place which was completed in 2003. The registered manager is aware that as repairs are being undertaken to the central heating system that this will need to be cleaned and tested in order to minimize risks of Legionella. Staff have received mandatory training in the required disciplines upon sampling records and training certificates. There are only a couple of areas which require improvement which are in relation to the control of substances hazardous to health and ensuring that all staff participate in a bi-annual fire evacuation drill. Food hygiene practice was observed to be adequate although all frozen foods need to be labelled with the date of freezing as previously required and perishable foods need to be labelled with the date of opening. The provider is forwarding copies of monthly visits undertaken by senior management to the Commission as previously required. These no longer required to be sent, as discussed with the registered manager. Copies of reports however still need to be held on the premises (made available to the 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 25 registered manager). The last report held on the premises is for a visit undertaken on 4 October 2006. 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 X 2 X X 2 X 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(1)(b) Timescale for action Review the statement of 01/09/07 condition of residency to include all information contained within Standard 5.2 of the National Minimum Standards for Younger People. (Previous timescale of 1/10/05 is partly met). To ensure that care plans are updated as and when resident’s needs change – for example to ensure that one resident’s mobility requirements to access the bathing facility are included in her care plan. To carry out a risk assessment with regard to one resident who requires some assistance from staff when accessing the bathing facility. To ensure that there is more consistent recording of daily food options chosen by residents. To improve the control and administration of medication in the following areas: 01/08/07 Requirement 2. YA6 15(1) 3. YA9 13(4)(c) 01/08/07 4. YA17 17(2) 01/09/07 5. YA20 13(2) 01/09/07 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 28 1) To continue to progress plans to ensure all staff have received training in the safe handling of medication from an accredited trainer. (Previous timescale of 1/1/04 is partly met). 2) To ensure keys to the drug cabinet are held separate to any other master keys. (Previous timescale of 1/9/05 is not met). 3) To ensure that the drugs cupboard is secured to the wall. 4) To ensure that the date of the receipt of medicines are recorded. 5) To ensure that when staff hand write any instructions onto MAR sheets that 2 staff initials are obtained to confirm that they have witnessed that the correct instructions have been transcribed. To ensure that all staff receive training in vulnerable adult awareness. (Previous timescale of 1/10/05 is partly met). To ensure more accurate recording and checking of residents’ personal expenditure sheets, petty cash vouchers and till receipts. To ensure that residents are not inadvertently charged for meals which are normally included as part of their basic contract fee. 6. YA23 13(6) 01/09/07 7. YA24 23(2)(b) To make the following improvements to the DS0000004804.V329989.R01.S.doc 01/09/07 5 Wellington Street Version 5.2 Page 29 environment: 1) To ensure all wardrobes are securely fixed to walls. (Previous timescale of 1/7/04 is not met). 2) To carry out a written risk assessment with regard to the use of electrical adaptors in documented liaison with the fire service. (Previous timescale of 1/10/05 is not met). 8. YA26 12(4)(a) To replace existing bedroom door locks with locks which have a thumb turn or other suitable over ride mechanism from the inside (and can be locked when not in use by the resident). (Previous timescale of 1/1/04 is partly met). To ensure that there is supply of liquid soap in toilets and bathrooms. 01/09/07 9. YA30 13(3) 01/09/07 10. YA32 18(1)(c) To ensure that mops are stored appropriately when not in use (for example not within the kitchen area). To provide training for all staff in 01/09/07 challenging behaviour. (Previous timescale of 1/10/05 is partly met). To ensure that 50 of the care staff team are qualified to NVQ 11 or above by 2005. (Previous timescale of 1/10/05 is partly met). 11. YA33 18(1)(a) To ensure that the duty rota is accurately maintained with all hours worked by staff and management. 01/08/07 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 30 12. YA34 19 To demonstrate that there is a rigorous recruitment and selection process – all preemployment checks must be undertaken as detailed in Regulation 19, Schedule 2 of the Care Homes Regulations 2001 (including a health care declaration and full employment history, photograph, written explanation of gaps in employment). Records must be maintained and available for inspection. To ensure all staff receive training in equal opportunities and disability equality. (Previous timescale of 1/10/05 is partly met). To review and update the central staff training and development programme. (Previous timescale of 1/5/06 is partly met). 01/08/07 13. YA35 18(1)(c) 01/09/07 14. YA37 18(1)(c) To ensure that the Registered Manager is qualified to NVQ 1V in care and management by 2005. (Previous timescale of 1/10/05 is partly met). To review and further develop quality assurance system to incorporate feedback from stakeholders and families. (Previous timescale of 1/5/05 is partly met). To make the following improvements to health and safety: To carry out a written risk assessment to identify and undertake control measures with regard to unsecured substances 01/09/07 15. YA39 24 01/09/07 16. YA42 13(4)(a) 01/09/07 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 31 hazardous to health which are held in the kitchen. (Previous timescale of 1/1/05 is not met). To ensure compliance with Control of Substances Hazardous to Health Regulations 1988 - carry out individual risk assessments on all products used and to update COSHH information. To ensure that all members of staff participate in a bi-annual fire evacuation drill. To ensure that all food frozen by the home is labelled with the date of freezing and use by date. (Previous timescale of 1/9/05 is not met). 17. YA42 13(4)(c) 01/09/07 18. YA43 26 To ensure that copies of the monthly reports from visits undertaken by the Owners representative are available on the premises. (Previous timescale of 1/9/05 is not fully met). 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations To consider introducing a more comprehensive nutritional screening tool such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’) in order to identify issues relating DS0000004804.V329989.R01.S.doc Version 5.2 Page 32 5 Wellington Street to malnutrition and obesity and which utilizes a Body Mass Index scoring system. 2. YA19 To consider introducing an improved system for monitoring residents’ weight such as weight charts, identifying when residents have lost or gained weight, and action to be taken by staff. To include the maximum days a PRN medication can be administered before seeking further medical advice onto the PRN guidelines. It is recommended that a running audit and balance is checked and recorded for medicines which are not dispensed into the monitored dosage system such as PRN medicines (this can be entered onto the MAR sheet). To continue to pursue helping all residents to open their own bank accounts. It is recommended that supervision records include discussions regarding work with individual service users. It is recommended that the home is enabled to access and use e-mail and web site facilities to assist with communication and researching current good practice and guidance. Appropriate facilities for communication by facsimile transmission should also be provided. 7. YA42 Perishable foods should be labelled with the date of opening. 3. YA20 4. 5. 6. YA23 YA36 YA37 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 5 Wellington Street DS0000004804.V329989.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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