Inspection on 21/04/06 for 51 Havacre Lane

This inspection was carried out on 21st April 2006.

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 33 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

51 Havacre Lane 24/05/07

51 Havacre Lane 06/12/05

51 Havacre Lane 29/03/05

51 Havacre Lane 12/10/04

51 Havacre Lane 18/03/04

51 Havacre Lane 17/02/04

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

CARE HOME ADULTS 18-65 51 Havacre Lane Coseley Dudley West Midlands WV14 9NP Lead Inspector Debbie Sharman Key Unannounced Inspection 21st April 2006 09:00 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 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 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 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. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 51 Havacre Lane Address Coseley Dudley West Midlands WV14 9NP 01902 409704 01902 493080 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) Black Country Housing and Community Services Group Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: Havacre Lane is a purpose built four bedded single bedroom house situated within walking distance of local shops and facilities, close to the railway station and public transport services. Other facilities include a lounge/dining room, kitchen, laundry, bathrooms and toilet facilities. The registered provider is a not for profit social landlord who offers long stay accommodation at the home for younger adults with a learning disability. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection, which is the first of the inspection year 2006 – 2007. It was unannounced meaning that nobody connected with the provision of service received prior notification and as such were unable to prepare. This inspection was a ‘key’ inspection meaning that performance against all key standards were assessed. The inspection began at 9.00am and finished at 6.00pm. The Inspector was able to talk to all four-service users, two of whom were happy to show the Inspector their bedrooms. The Inspector also interviewed a staff member about adult protection issues and general training that he had received. The administration of medication to service users was also observed. The Inspector toured the premises, case tracked care provided to a service user and aspects of care provided to others. Examining documentation held in relation to a recently appointed staff member provided the opportunity to assess recruitment processes. This also gave the Inspector the opportunity to talk with an employee from the human resource department at Head Office who brought the staff member’s file to the home. The Acting Manager supported the inspection process throughout the day. Feedback/comment cards have been provided to service users by the Commission for Social care Inspection who have been supported by staff to complete them. Comments received are generally positive about all aspects of care. All service users who answered though said that they ‘usually’, rather than ‘always’, make decisions about what they do each day. Progress towards previous requirements issued for improvement was also assessed. Although there are a disproportionate number of outstanding requirements for improvement for a small home this inspection has seen the home meet more requirements than it has received indicating progress. Some progress has been made particularly where it has been within the Acting Managers remit to make the necessary improvements. Action requiring the intervention of the provider is holding back the homes development, for example with improvements to the premises and also recruitment processes, which are managed centrally. Weekly fees range from £1,062.01 to £1,068.92 What the service does well: 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 6 Service users are happy. This was evident from what they said to the Inspector and from observations of those who are less able to articulate their feelings and opinions. Bedrooms are personalised and staff know service users individually. Service users access the local community and during the inspection some service users went out for lunch to a local café with one service user opting to stay at home. The home is clean with no odours and infection control practice is satisfactory. The home has sufficient staff who have been trained in first aid and assessment of the rota showed that there is always a first aider on duty. A staff member verbally demonstrated a developed understanding of adult protection issues and his role in relation to the protection of vulnerable adults. Havacre Lane has a positive atmosphere. The Acting Manager, staff and service users supported the inspection and thanks are extended to them all. What has improved since the last inspection? What they could do better: The conduct and management of the home is a concern. The Acting Manager has worked hard to make some improvements. The Commission for Social Care Inspection has not however received an application to register a Manager in respect of this home. This was raised during the inspection with the Acting Manager who said she has decided not to apply for the registered Managers position. She does not feel that the provider is taking action sufficiently quickly to make the required improvements and this has impacted upon her 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 7 decision not to apply for the permanent managers position. Lack of progress in the provision of an out of hours emergency Management system has also impacted on the Acting Manager’s decision as this omission she feels negatively impacts upon her work/life balance. Havacre Lane has been without a registered Manager for too long and the provider must now address this as a matter of urgency. The home is not assessing its own performance based upon service user and others feedback. A quality assurance system purchased has not been implemented. The Commission for Social Care Inspection was not notified by the provider of a staff dismissal in January 2006, and there is no evidence that the provider has considered its duty to refer the matter to the POVA list. Furthermore induction for new staff to the required national standard is not being provided and the Inspector was not reassured that any progress had been made in this respect. The premises continue to deteriorate and are not providing a homely and wellmaintained living environment for service users. Holes in walls in the entrance have been replastered but have since obtained further holes and cracks. This plasterwork remains exposed, as it has not been decorated over. Wallpaper in communal areas is unacceptably ripped and generally worn. Timescales set by the provider for improvement to the premises have passed without action and service users have not been informed when their home will be decorated. An improvement in systems to ensure that the nutritional and dietary needs of service users are assessed and met, remains outstanding. 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. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 8 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 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Assessments systems are poor. Systems are not in place for the home to assess prospective service users individual aspirations and needs prior to admission. EVIDENCE: This standard has not been assessed for three previous inspections as Havacre Lane has a stable service user group that has not changed. This inspection again found there to be no discharges and no new omissions. The home does not have any service user vacancies. The home does not have a pre admission assessment proforma readily available for use should this situation change. Action plans submitted previously to CSCI in respect of this have said that this will be carried out when necessary. It would however make sense to develop a system prior to the time when it will be needed. Community Care assessments undertaken by the placing social workers for current service users are not available and therefore it was not possible to assess whether service users assessed needs were being met from the point of admission to the home. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Care planning is satisfactory. Most but not all of service users needs are addressed in their plans of care. Plans of care include attention to risk management but do not support decision making for more dependent service users. EVIDENCE: One service users care plan was case tracked and it generally meets his needs. There are however some omissions and some omissions of detail. For example the need for a ‘low fat’ diet is not sufficiently specific to guide staff when purchasing food and designing menus. Detailed advice given by a dietician has not been transferred to the care planning system. Care plans are also not person centred and have not been agreed by service users or their representatives. However minutes of a multi disciplinary review meeting show that the service users relative is satisfied that the care provided is meeting the service users needs. Documents show that service users are consulted and their decisions are noted and acted upon generally. However it is evident that those service users who are able to articulate in service user meetings mostly make the decisions. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 11 There was less evidence of good practice in relation to decision making for service users who are less able to contribute in decision-making forums such as residents meetings. Furthermore care planning for these service users does not include guidance for staff in respect of how to support these service users to make decisions. Improvements in systems will better support staff to support service users. Comments in feedback cards provided by CSCI and completed by service users with support from staff are generally positive about all aspects of care. All service users who answered though said that they ‘usually’ rather than ‘always’ make decisions about what they do each day. There is a range of risk assessments in place for each service user, which accounts for any restrictions made in the service users best interests. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16, and 17 The provision of appropriate and fulfilling lifestyles is generally good. Performance is mixed with most activities provided meeting service users wishes and preferences and some not. Service users contact with family and friends is actively promoted and personal care is provided well. Systems to better support service users nutritional needs require improvement. EVIDENCE: For the service user case tracked there was some correlation between activities he is assessed as enjoying and activities he has been supported to take part in. There was also good evidence of regular contact with family for the service user in accordance with his assessed need. Records evidencing activity outcomes continue however to show a large proportion of this service users time is spent ‘relaxing’ which does not concur with his assessment of need. There is also evidence that this service user is joining in, group activities that he would not necessarily choose to do and has in residents meetings stated he does not want to do e.g. shopping. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 13 Discussion with another service user showed her delight at a recent day trip to Tewkesbury where she had for the first time experienced a boat trip. Trips to other places of interests locally were also evidenced. Preferred routines are assessed well and are therefore known to staff. The Inspector observed an informality of routine with service users rising and undertaking personal care in accordance with their preferences. Service users preferred foods are known and there was evidence within records that preferred meals are provided. However, systems to support service users nutritional and dietary health require improvement. For example nutritional assessments have not been undertaken to show the level of nutritional risk, care plans do not contain sufficient guidance, healthy weight ranges for individual service users are not known and food stocks observed do not fully comply with the need to provide low fat diets to some service users. However, said that, assessment of weight records for one service user show positive outcomes with him having lost 12 pound in weight in the previous 3 months. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The management of personal care is good with personal care being provided in accordance with expressed wishes and preferences. Changes in health are responded to but omissions in routine health screening remain. The administration of medication must also improve to protect service users health and welfare and therefore the management of health is not satisfactory. EVIDENCE: Preferred routines are assessed well and are therefore known to staff. The Inspector observed an informality of routine with service users rising and undertaking personal care in private and in accordance with their preferences. There is good evidence that a change in service users health is noticed and responded to without delay. Record systems to monitor routine health screening have improved and there was evidence that one service user had been supported to attend outpatient appointments at hospital for specific health needs. There was however no evidence of dental, chiropody or well man screening. Hearing tests. There was evidence that a request, has been made and been followed up but the waiting list is lengthy. Care notes had not been updated to explain why a follow up blood test had not been provided as indicated in earlier records. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 15 The Inspector observed the administration of medication. Areas for improvement were identified including leaving medication unattented in the kitchen whilst the person responsible for administering went elsewhere, the need to hand wash more frequently before during and after administration, the lack of use of personal care gloves whilst administering eye drops and failure to wash hands after such and signing for the administration of medication prior to its administration. Storage, ordering, delivery and return of medication is appropriate. The supplying pharmacist undertakes regular support visits with few recommendations for improvement. Medication prescribed as ‘as required’ to manage behaviour is used infrequently and safe guards are in place for this with permission to administer being sought by staff. Prescribing directions need clarifying with the GP. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Complaints and protection outcomes for service users are generally satisfactory. EVIDENCE: A previous requirement to ensure that complaints procedures are in an accessible format for service users has been met. A pictorial guide is available in each service users bedroom and a service user was able to tell the Inspector what action she would take in the event of dissatisfaction. There was evidence that how to make a complaint has been discussed with service users in residents meetings. The complaints procedure is brief but satisfactory covering all required areas. Service users do not currently have independent advocates assigned to them but have done so in the past and the Acting Manager is aware of circumstances that may necessitate their use. Advocacy information is not freely available within the home to service users and the Manager is required to address this omission. No complaints have been made to the home or to CSCI since the last inspection. The homes Adult Protection policy has been improved since the last inspection. Service users are no longer charged inappropriately for meals taken at the day centre and reimbursements have been made. A staff member verbally demonstrated knowledge of the need to adhere to service users individual behaviour plans, one of which has been updated as required. This staff member also has a good understanding of adult protection issues and has received appropriate training. The service user whose behaviour was presenting difficulties at the last inspection presents as calmer and there have been some, but fewer, behaviour incidents. Records of incidents were 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 17 assessed and intervention appears to have been proportional and positive. A policy on staff involvement in making service user wills remains required. Small gifts to staff are declared and recorded openly and transparently to protect both staff and service users. Financial records are appropriately maintained on behalf of service users and it was pleasing to see a service user who is able to sign for receipt of her own money. The dismissal of a staff member following investigation in January 2006 has not been notified to CSCI and the considered possibility of referral to the POVA list could not be evidenced. Disciplinary records were not available to the Inspector as per regulation. The Inspector was assured that these would be retrospectively provided. A staff member spoken to felt that service users are safe within Havacre Lane. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Service users live in a generally comfortable and safe environment but the internal décor is poor and continues to deteriorate with no plan for improvement. EVIDENCE: The premises are domestic in size and style. The lack of progress since the last inspection to improve the homes décor is disappointing and bare plaster work and ripped worn wall paper is not homely. Minor work has been undertaken such as fixing a broken grab rail and tile in the bathroom but works requiring capital expenditure has not. Infection control practice continues to be satisfactory although the Acting Manager described a concerning incident that took place in January 2006 where an unexplained foul odour that permeated the building lead to the discovery of a decomposing substance within a staff toilet area. Investigation of the incident has not drawn any definite conclusion although the Manager and staff have drawn an unproven conclusion. Freezer temperatures are not being recorded accurately but the Manager explained that a new freezer has been ordered. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 19 The Infection Control Nurse audited the premises in 2004, the Environmental Health Department visited in January 2006 leaving some statutory requirements for improvement and the Fire Officer last visited in July 2005. Magnets for doors required by the Fire Officer have not been provided but the Acting Manager assured that they have now been ordered and delivery is imminent. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Performance in relation to staffing is mixed but satisfactory overall with some improvements evidenced. EVIDENCE: Previously omissions in training, recruitment practice and staff supervision have been of concern. There have been some improvements in all three areas. A staff member spoken to has been provided with a wide range of training with few omissions but certificates are not always available to evidence this. The most significant omission with respect to training now is the lack of induction for new staff to the required national standard and the ongoing lack of progress to implement this. Most staff have now received four formal supervision sessions in 8 months with the Acting Manager who is on target to have provided the minimum of six within 12 months. Supervision records are detailed and frank. Criminal Record Bureau checks are in place for two new staff case tracked and there is evidence that service users have been offered appropriate protection as these were secured prior to their employment. There was however no identification on file, no evidence that new staff are physically and mentally fit for their role and references provided for one staff member did not tally with the work history. There was also no evidence that qualifications / training had been verified with the applicants prior to employment. Front sheets or audit 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 21 matrices are not being used to support the identification of missing documentation. Havacre Lane does not enjoy full staff occupancy and this does not provide service users wit stability. One of the first questions a service user asked the Manager is ‘when are we having a new manager?’ Staffing levels are being maintained through use of agency staff but moves to fill permanent vacancies are slow and bureaucratic. For example agency staff wishing to move to permanent employment with the provider are being thwarted by slow negotiations over contracts and fees. Furthermore Acting Manager arrangements and maternity leave has resulted in the home being 42 senior care hours per week short and 21 care hours short following a dismissal in January 2006. The Acting Manager informed the Inspector that the creation of a Deputy Manager post has been agreed. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The home has made some limited improvements under the current temporary management arrangements. The day-to-day management of the home is satisfactory but systems are not sufficiently in place to actively promote the continued development and improvement of the home based upon selfassessment and feedback from customers. EVIDENCE: The conduct and management of the home provides some concern. The Acting Manager has made some improvements. The Commission for Social Care Inspection has not however received an application to register a Manager in respect of this home. This was raised during the inspection with the Acting Manager who said she has decided not to apply for the registered Managers position. She does not feel that the Provider is taking action sufficiently quickly to make the required improvements and this has impacted upon her decision not to apply for the permanent managers position. Havacre Lane has been without a registered Manager for over 12 months and the provider must now address this as a matter of urgency. The home is not assessing its own performance based upon service user and others feedback. A quality 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 23 assurance system purchased has not been implemented. The Commission for Social Care Inspection was not notified as per the provider’s regulated duty of a staff dismissal in January 2006 and there is no evidence that the provider has considered its duty to refer the matter to the POVA list. Furthermore induction for new staff to the required national standard is not being provided and the Inspector was not reassured than any progress had been made in this respect. The premises continue to deteriorate and are not providing a homely and wellmaintained living environment for service users. Holes in walls in the entrance have been re plastered but have since obtained further holes and cracks. This plasterwork remains exposed, as it has not been decorated over. Wallpaper in communal areas is unacceptably ripped and generally worn. Target dates set for improvement have been exceeded and the requirement to provide an action plan for improvement to CSCI has also not been met. A maintenance and improvement plan is not in place. This reflects poorly on the conduct and management of the home. The Fire Officer was satisfied with fire precautions at his last visit in July 2005, the Inspector was told with the exception of the provision of magnetic doors. These have not to date been provided but have been ordered. A staff member verbally demonstrated knowledge of the fire procedure and location of exits. Fire drills are held regularly but fire alarm point tests are not being recorded fully. Fire training was last provided in November 2005 but Fire training could not be evidenced for one staff member since April 2004. Early fire instruction following the commencement of employment could not be evidenced. Advice must be sought from the fire service to indicate at what stage following employment fire training should be provided. Water temperatures are taken and advice about water temperatures in the kitchen and laundry has been obtained from Environmental Health who have also required the home to take action in respect of radiator and pipe temperatures. Action to comply has not been taken. Environmental Health have also required action in respect of accident reporting, asbestos and have recommended action in respect of visual safety checks of electrical appliances. As previously required COSHH assessments have not been undertaken based on data provided by the manufacturers of hazardous chemicals but all such chemicals were appropriately stored. Accident records show few accidents (8) of a minor nature and with no obvious trends. There is a well-stocked first aid box and sufficient first aid qualified staff to adequately cover the rota. Not all windows are fitted with window restrictors including some key windows. The Acting Manager had not been aware of this and this omission is not enabling the home to comply with the risk assessment it has in place in respect of this issue, compromising the security of the premises. Maintenance and service records were available and up to date with the exception of portable appliance electric tests, which must be submitted to CSCI to evidence electrical safety. Steps have been taken since the last inspection to secure a television in a service users bedroom reducing risk to the service users and to others. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 24 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 1 3 X 4 X 5 X 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 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 1 X X 2 X 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 25 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 YA2 Regulation 17(1)(a) Requirement Residents case files must include a detailed pre admission assessment carried out by the home prior to admission. No new admissions at July or December 2005 or at April 2006. Care plans must include arrangements to meet assessed dietary needs. Requirement first made and not met since October 2004. Advice provided by dietician must be incorporated into the individuals care plan. Residents and/ or their representative must sign the care plan to evidence participation and agreement. Requirements first made and not met since February 2004. Timescale for action 31/07/06 2. YA6 15 17(1)(a) Sch 3.3m 31/05/06 3. YA6 15 31/05/06 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 26 4. YA6 15 17(1)(a) Sch 3.3m Nutritional assessments must be undertaken for all service users and action taken where and if risk is identified. Care plans must include safe weights for service users based upon clinical guidance. New Requirement at December 2005 and not met at April 2006. 31/05/06 5. YA7 15 Care plans must include all aspects of decision-making. This requirement was made and has not been met since March 29th 2005. 31/05/06 6. YA12 12(2)12(3)20 31/05/06 The manager must ensure that an advocate or independent representative is engaged to support residents decision making with respect to the provision of a communal mini bus where the proposal is for residents to fund it. At April 2006 – no progress made towards obtaining a vehicle 7. YA13 12(2)12(3)15 Service users must be enabled to be politically active and to vote should they wish to. Requirement first made and not met since October 2004 and not assessed at April 2006. 31/05/06 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 27 8. YA16 5(b) The homes rules on smoking, alcohol and drugs must be included in the terms and conditions of residency contract. Requirement first made and not met since February 2004 30/06/06 9. YA19 12,13 The manager must ensure that residents are offered as a minimum annual health screening checks including vision, hearing and testicular screening. At December 2005 hearing screening referral made. Still awaited at April 2006. Not Met 30/06/06 10. YA20 13(2) Lactulose medication prescribed three times per day but not administered to the service user must be reviewed with the GP and the outcome recorded and advice followed. New Requirement at December 2005 and not met at April 2006. 30/04/06 11 YA20 13(2) The Acting Manager must 30/04/06 take action to ensure improvements in the administration of medication with attention to: 1. Safeguarding service users by attending to medication during administration at all times 2. Hygiene practices during administration 3.Clarify prescribing 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 28 directions with the GP where they are not specific i.e. ‘as directed’ Action taken must be confirmed in writing to CSCI New Requirement at April 2006. The Acting Manager must ensure that Advocacy Services information is readily available to service users. New Requirement at April 2006. A policy on staff involvement in making service user wills must be available within the home. This requirement was made March 29th 2005. Not Met Fire instruction for new staff must be provided early in induction and must be recorded. Requirement first made February 2004. No new staff appointed at July 2005. No new staff at December 2005. Not met for new staff member at April 2006 12 YA22 22 31/05/06 13 YA23 13(6) 31/07/06 14. YA24 23(4) 30/04/06 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 29 15. YA24 13,23 Have readily available a planned program for the maintenance and renewal of the fabric and the decoration of the premises. Requirements made November 2002 – Not Met 30/06/06 16. YA24 23(2)(b)(d) Action must be planned to make good the following: Redecorate the lounge and dining room area Redecorate the laundry Repair damaged plaster work at foot of stairs Redecorate in washable paint areas that have deteriorated since being recently painted. An action plan with target dates based upon priority must be provided to the Commission for Social care Inspection (by the date set) New Requirement at April 2006 An action plan with target dates must be provided to the Commission for Social Care Inspection to address the need to refit / retile / replace flooring in the kitchen and both bathrooms ensuring bathrooms are homely. New Requirement at December 2005 – Not Met 31/05/06 17. YA24 23 31/05/06 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 30 18. YA26 23 The provider must provide the service user with the furniture prescribed in the National Minimum Standards. If it is the service user wish not to have these items or they would present a risk, it must be clearly stated what the service user wishes are and evidence of a risk assessment provided. Requirement made November 2002 – Not Met 31/05/06 19 YA33 18 31/05/06 An action plan to permanently address the following vacancies must be forwarded to CSCI and must be acted upon: Registered Manager Senior Carer Support Worker. New Requirement at April 2006. All staff files must fully comply with the requirements of Schedule 2 and all staff files must be audited to check compliance. A matrix for all staff recruitment files must be undertaken demonstrating documents that are available and missing. A written action plan must be developed to address any omissions. 20. YA34 19 31/05/06 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 31 The matrix and the action plan must be made available to the Commission for Social Care Inspection on 7th April 2005. These requirements were identified for immediate action at March 2005 and at July 2005 – Not Met 21. YA34 18 To review the high use of agency staff and provide a written action plan to CSCI by 22/07/05 New Requirement at July 2005 – Not Met. 22. YA34 19, 9, 13(6) All recruitment documentation as per Schedule 2 must be appropriately in place prior to the commencement in employment of any staff member. This requirement was made and has not been met since March 29th 2005. The provider must improve performance to the required standard in relation to recruitment ensuring that satisfactory and sufficient documentation as regulated and in accordance with Schedule 2 is obtained prior to the appointment of all staff and manager applicants. The provider must confirm in writing to the Commission for Social Care Inspection how it is 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 32 31/05/06 30/04/06 intended to improve performance in relation to recruitment. This must be forwarded by Friday 15th July 2005. This was issued as an immediate requirement at July 2005. 23. YA35 Not Met at April 2006 18(1)(a)18(1)(c) Induction to the required Standard must be provided. An action plan must be supplied to the Commission for Social Care Inspection indicating how this will be met with target dates. All training certificates for all staff must be available to evidence training undertaken. Training in equal opportunities, disability equality training and anti racism training must be provided for all staff and evidenced. Dates must be booked by the date given. This requirement was made and has not been met since March 29th 2005. 24. YA36 18 Staff must receive supervision a minimum of six times each in a 12month period. Period to assess July 2005 July 2006. 12/07/06 31/05/06 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 33 New requirement at July 2005. Some progress at December 2005 and at April 2006. 25. YA37 9 The provider must ensure that an application be forwarded to the Commission for Social Care Inspection for Registration of a manager. This (amended) requirement was made and has not been met since March 29th 2005. 26. YA39 24 The provider must ensure that an effective quality assurance mechanism is implemented. This requirement was made and has not been met since March 29th 2005. 27 YA41 17(2) Sch 4(6)(f) Disciplinary Records must be available for inspection. Disciplinary records / outcomes from incident in Jan 06 must be forwarded to CSCI. New Requirement at April 2006. COSHH assessments must be updated to accurately reflect the substances being used within the home. This requirement was made and has not been met since March 29th 2005. 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 34 30/06/06 30/06/06 30/04/06 28. YA42 13(4) 31/05/06 29. YA42 13(3)(4) Staff must read and sign all COSHH assessments to evidence understanding. This requirement was first made and not met since February 2004 31/05/06 30. YA42 13(3) 18 Manager (or delegate) must undertake the Intermediate Food Hygiene Award. Requirements first made and not met since February 2004. 30/06/06 31. YA42 18, 23 . Provide the CSCI with evidence to show that checks for Legionella have been carried out. Requirements first made and not met since November 2002. 31/05/06 32. YA42 23(4)C(i) The provider must ensure that fire systems are tested regularly in house and that these tests and the outcomes are recorded. New Requirement at December 2005. 31/05/06 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 35 33 YA42 23 Evidence of up to date Portable appliance tests must be forwarded to CSCI by the date set. The Acting Manager must take action to ensure that the risk assessment in place in relation to the safety of windows is adhered to. Action taken must be confirmed in writing to CSCI. New Requirement at April 2006. 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 36 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: 0845 015 0120 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 51 Havacre Lane DS0000025011.V290227.R01.S.doc Version 5.1 Page 37 - 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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