Inspection on 06/12/05 for 51 Havacre Lane

This inspection was carried out on 6th December 2005.

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 41 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 21/04/06

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 Unannounced Inspection 6th December 2005 10:00 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 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.V270836.R01.S.doc Version 5.0 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.V270836.R01.S.doc Version 5.0 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 Elaine Ball Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 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.V270836.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second statutory inspection of this inspection period to be carried out at Havacre Lane. This inspection was unannounced meaning that neither the Acting manager, staff no service users had prior notification and were not able to prepare. The inspection, which was conducted by one Inspector, began at 10.00am and finished at 6.oopm. The Inspector planned to assess those key standards not assessed at the previous inspection. The Inspector was able to interview the Acting Manager who supported the process throughout the day, tour the environment, interview two service users one of whom showed the Inspector her bedroom. Documentation was also assessed. Evidence was assessed to guage to what extent the home has made improvements previously required by the Commission for Social Care Inspection. Twelve previous requirements issued to ensure improvement have been judged as fully met and have been deleted from this report. What the service does well: What has improved since the last inspection? The supervision process has begun with some staff having received two formal supervisions since the last inspection. These meetings have been well documented. Training levels have improved with all staff having received Adult Protection training. Progress has also been made with medication training, first aid training and food hygiene training which will better equip staff to meet service users needs and will also better protect them. The Acting manager feels that the home is now better responding to incidents by ensuring investigation. This is evidenced by a better response to discrepancies in medication administration. This is helping to ensure that all staff are more accountable for their practice. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 6 Some previous requirements to ensure improvement have been fully met and have therefore been deleted from this report. A quality assurance tool has been purchased since the last inspection and although it has not been used yet is now available for use. This will enable the home to better assess its own performance and to take action where it identifies the need to make improvements. Significant omissions in health screening for service users has begun to be addressed. Health was not fully assessed at this inspection but service users who had not been helped to obtain optical screening had done so by this inspection with one service user receiving new glasses as a result. What they could do better: The premises require improvement to ensure that service users continue to live in a pleasant and homely environment. Improvements that have been made recently have rapidly deteriorated. For example the marks on decorated new paintwork make it difficult to now recognise that this work has been recently done. The paint used is not cleanable. Plasterwork on the wall at the bottom of the stairs is broken down to the brickwork. Wallpaper in the lounge is ripped in several places and its redecoration is two months overdue. A tile near the bath is broken and sharp. Tiles in the bathrooms have been patched and are mismatched. The bathrooms are not welcoming and need to be completely refitted. The kitchen is also looking tired and financial planning is required to ensure that funds are available to replace it. Repairs to the premises are slow to be provided. The Acting manager feels that response times are becoming slower. A grab rail in place to promote service users safety whilst getting in and out of the bath came off approximately three weeks prior to inspection and by the day of inspection had not been replaced. The home’s Adult Protection policy remains in need of updating to ensure that staff are appropriately guided in the event of an incident or allegation. Inventories of service user possessions when in place will also provide better safeguards. Service users are funding their own meals when attending day centres which is not acceptable. Some aspects of medication practice require improvement and in house checks of the fire alarm system must be recorded so the acting manager can demonstrate duty of care. The manager has since the last inspection obtained updated written information from the suppliers of hazardous chemicals used in the home but has not used this information to undertake risk assessments to limit the risk to service users and staff. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 7 Recruitment checks to confirm the ongoing suitability of agency staff supplied to the home needs to be updated and reviewed. The home is not currently evidencing that it is fully meeting service users nutritional needs and improved systems and understanding are required. 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.V270836.R01.S.doc Version 5.0 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.V270836.R01.S.doc Version 5.0 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): EVIDENCE: These Standards were not assessed at this inspection. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 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): 7, 9 Service users make decisions about their lives with assistance as needed. Care plans and records do not provide staff with sufficient guidance about decisionmaking. Service users are generally supported to take minimised risks where risks are identified in accordance with their wishes and preferences. EVIDENCE: The previous requirement to include decision making on service users care plans has not been met. However a service user told the Inspector that service users could make decisions about their lives. The service user said ‘I can choose anything’. In response to the question ‘do other people make decisions for you?’ the service user said ‘no, I can do it myself. Nobody ever tells me’. This service user added that she can go to bed at any time and that this decision is ‘up to myself’. The service user said that service users themselves choose what to eat and that alternatives are provided and that there are daily opportunities to go out and undertake favourite activities. This service user told the inspector that she manages her own money and chooses 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 11 what she spends it on ‘because it is my money’. The Acting Manager confirmed this arrangement. The service user had no complaints about opportunities available to make decisions. Care plans must include decisionmaking processes and records must indicate where decisions are made by others for those less able to make decisions. There have been previous concerns about the risks associated with a service user smoking in the bedroom. This inspection has shown progress. Steps have been taken to improve safety in the bedroom through the provision of fire retardant bedding and soft furnishings, a chair to prevent the service user sitting on the bed whilst smoking, a table with a large ashtray. This service user showed the Inspector these facilities in her bedroom and demonstrated a very good knowledge of the system in place. She demonstrated that she fully understood the ‘rules’ and the reason for the rules but appreciates some autonomy, as smoking is very important to this service user. A comprehensive fire risk assessment is in place that this service user has also signed. This represents a significant improvement. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 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, 15, 16, 17 Service users are able to take part in age appropriate activities, are able to maintain contact with family and friends, and their rights are respected. Service users enjoy their meals but systems to assess and respond to identified nutritional need are not in place to maximise service users health opportunities. EVIDENCE: These Standards were largely assessed by discussing with service users their experiences. A service user told the Inspector that it is possible to ‘go out all the time’. The service user said ‘every day I go out’. The service user attends a day centre Monday to Friday and said that this is enjoyable. In addition the service user said that she goes out a lot at weekends and evenings to pubs, discos, karaoke’s and day trips. It was planned for the service users to go to the pub on the night of the inspection. The service user confirmed that she undertakes the things that she likes to do. In her bedroom she showed the Inspector some knitting that she is working on. Some records were seen which evidence that service users requests for activities are listened to and acted upon. For example, the minutes of service user meetings show that service users had requested a variety of days out over the summer period most of which had been honoured. The Acting Manager is aware of the 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 13 existing requirement to ensure greater correlation between day-to-day activity plans based upon assessed need and evidenced outcomes for service users. The Acting Manager said that she is beginning work on this and that improvement will be evident at the next inspection. Records were not assessed of how the home ensures contact between service users and friends and family. A service user told the Inspector that she sees her family ‘a lot’ with family visiting her at Havacre Lane and the service user visiting family for overnight stays at times. A previous requirement issued to ensure that the home’s rules on smoking. Alcohol and drugs is included in the service users contracts have not been met to provide new service users with clarity. Recent improvements have in practice meant that a service user who smokes has been helped to become familiar with safety systems, which affect her smoking practices. Staff interact positively and respectfully with service users who are encouraged to be involved in all aspects of the home from small domestic tasks to shopping for the home. A service user said the staff are ‘nice staff, good staff’. A service user told the Inspector that she has ‘nice dinners’ at Havacre Lane. She said that her favourite is sausage and chips and that she is able to have her favourite meal. In response to the question ‘do you have enough to eat?’ the service user replied ‘yes, plenty’. A second service user confirmed that the dinners are nice and that he likes living at Havacre Lane because he likes the chips. The previous requirement to obtain weighing scales to monitor service users health has been met and weights are now regularly taken and recorded. A dietician has been supporting two of the service users and has recently discharged them. Records are being kept now to evidence service users nutritional intake, which also shows that requests for different meals are being respected. The Acting Manager plans to review the menus to ensure that more choices are available and planned for at lunchtime. Care plans need to provide better guidance on weight and nutrition. For example although all service users weights are being taken regularly which demonstrate a rise in weight by nine pound in 12 months, it is not known whether one service user is underweight making the task of weight taking without purpose. Nutritional assessments must be undertaken to ensure that appropriate action can be taken when a service users weight becomes cause for concern. Service users are funding their own lunches at day centres and then being provided with a light tea on return to Havacre lane because they have had their main meal at the day centre. The home is obliged to provide and fund three meals daily including at least one cooked meal and a range of drinks and snacks. Meals taken at day centres must be funded by the home and the 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 14 home must refund meals funded by service users to date. The individual’s preference to take a hot meal at the day centre must be respected. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 15 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): 20 Systems to support the administration of medication have improved and for the most part are satisfactory. Errors identified in following the prescriber’s instructions during the administration of medication are the greatest concern and put service users safety and health at risk. EVIDENCE: Written protocols to provide staff with guidance on medication issues such as errors have improved. There is also now a written protocol for the transportation of medication that the Acting Manager says was overseen by the supplying pharmacist. However the policy does not guide staff to ensure that in the event of death that all medications must be retained. Senior staff are now auditing medication records weekly and anomalies are being investigated. This has highlighted a number of errors including some examples of non administration. There was evidence that all staff (with the exception of one missing certificate) have received medication training some as recently as August and September 2005. The supplying pharmacist is providing regular support visits with records showing that the pharmacist has not identified any major concerns. Ordering, receiving and returns of medication procedures are appropriate. Medication is also suitably stored. Care plans include updated information 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 16 about prescribed medication for each service user. Assessment of medication stocks showed no concerns. An investigation following the previous inspection showed that Zopiclone medication had been wrongfully administered, as a change in prescribing directions had not been appropriately responded to and implemented by staff. This inspection has shown that medication prescribed to be taken three times a day has been (and always has been) administered ‘as required’ by staff with the outcome being that it is not being given because staff feel it is not needed. Staff are not medically qualified to make this decision. If their observations lead them to believe there has been a change in the condition of a service user, which warrants a reduction, or increase in medication they must discuss this with the medical officer who prescribed the medication and adhere to any new, recorded directions. The circumstances identified by the Inspector must be reviewed with the service users GP, the outcome recorded and adhered to. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 17 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 Appropriate documentation to permanently remind service users how to make a complaint is not available. There is evidence that service users views are listened to and acted on. Service users are not fully protected by adult protection written guidance, behaviour management, systems to track service users possessions or financial policy and practice. EVIDENCE: The previous requirement issued to ensure that a complaints procedure is in a suitable format and prominently displayed for service users has not been met. A log to record any complaints received is also not in place. However it was pleasing to see that minutes of service users meetings provide evidence that how to make a complaint has been discussed with service users in July and November this year. A service user spoken to said that she didn’t have any complaints but indicated that she would know who to speak to if she did. The policy that is in place includes the details for the Commission for Social Care Inspection, assures potential complainants that they will not be victimised for making a complaint and resolves to respond to complaints within 28 days. An anonymous complaint sent to the Commission for Social Care Inspection after the last inspection was investigated and responded to by the home’s Responsible Individual or Area Manager. However the home’s Acting Manager had not been made aware of its receipt or outcome. Some steps have been taken to improve outcomes for Adult Protection since the last inspection. For example all staff have now attended Adult Protection 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 18 training and their attendance is certificated. There is a policy guiding staff should they be offered gifts or bequests from service users but this does not sufficiently guide them about any staff involvement in service users will making activity. National and local multi Adult Protection agency guidance documents are available on the premises and the home has its own policy to provide guidance in the event of there being an adult protection incident or allegation. This policy is broadly compatible with the spirit of national and local guidance with the exception of one statement which reserves the right to initiate an internal enquiry in the event of a prolonged investigation. This significantly contradicts local agreements and risks jeopardising a Police or Social Service enquiry. Significantly too there is no reference to referral to the POVA list either temporarily or permanently in the event of a concern in relation to a staff member. This inspection contains some on going concerns about behaviour management. The previous requirement to ensure that behaviour plans are adhered to has not been met. Behaviours have significantly escalated for one service user and multi agency reviews are in place to support the home. However incident records show a staff member ‘asked him to…’ but the staff members request was ‘ignored’. Guidance clearly states that requests must be repeated several times to avoid escalation of behaviour. The behaviour management plan for this individual is dated July 2004 and as such is 18 months old. His behaviours have changed since this time and triggers are less clear and behaviours arise with less warning. The behaviour plan has not been amended and therefore sufficient guidance is not being provided to protect staff and service users. Financial systems in place to protect service users money were assessed with the accounts of one service user sampled being inspected. Records are sufficiently detailed with receipts retained. Cash in hand was counted and tallied with the written balance. One service user holds and manages her personal allowance herself providing independence and maintaining dignity for this service user who is assessed as able to do this. There are two areas identified for improvement. Firstly, service users must not fund their own lunches and must be reimbursed for those funded to date. The Acting Manager expressed concern about how the budget would meet this. Secondly an inventory, that is undertaken on the first day of admission and subsequently updated and amended, must be in place for each service user to safeguard their possessions. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 19 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, 30 Havacre Lane is homely (with the exception of bathrooms), comfortable and generally safe but the environment is deteriorating and requires significant investment to ensure that the premises are made good and prevented from further deterioration. Infection control procedures have improved. The home provides a clean living environment for service users. EVIDENCE: Havacre Lane which is in keeping with and offers access to the local community is a long term home to four permanently placed service users who are mobile. Maintenance records indicate that the home’s infrastructure is maintained to maximise safety e.g. gas, electric, fire system servicing, fire drills, water temperatures etc. There was evidence that the water system has been chlorinated but no evidence that the provider knows whether there is legionella or other bacteria present in the water system. This has been subject to ongoing requirement. Inspection showed bedrooms to be personalised, warm and individually decorated to a good standard. Havacre Lane is however not yet providing all 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 20 bedroom furniture as per National Minimum Standard and has not accounted for why not it is not (e.g. lockable cupboard and second chair). Environmental Health last undertook a Food Safety visit to the home in July 2004 and the Fire Service visited more recently in August 2005. Fire systems are being serviced but regular in house fire system checks are not being recorded and are therefore not evidenced. The home has a planned maintenance and renewal programme in part but information is not available to the Acting Manager when many of the jobs listed were last undertaken. The written programme cannot therefore be completed and is not effective. It is not effectively driving the maintenance programme given that some jobs are now overdue e.g. redecorating the lounge. The premises require improvement to ensure that service users continue to live in a pleasant and homely environment. Improvements that have been made recently have rapidly deteriorated. For example the marks on decorated new paintwork make it difficult to now recognise that this work has been recently done. The paint used is not cleanable. Plasterwork on the wall at the bottom of the stairs is broken down to the brickwork. Wallpaper in the lounge is ripped in several places and its redecoration is two months overdue. A tile near the bath is broken and sharp. Tiles in the bathrooms have been patched and are mismatched. The bathrooms are not welcoming and need to be completely refitted. The kitchen is also looking tired and financial planning is required to ensure that funds are available to replace it. Repairs to the premises are slow to be provided. The Acting manager feels that response times are becoming slower. A grab rail in place to promote service users safety whilst getting in and out of the bath came off approximately three weeks prior to inspection and by the day of inspection had not been replaced. The Inspector was concerned that a television in the bedroom of one service user who presents challenging behaviour and who has been known to throw objects out of the window has a television sitting unsecured up high on a television bracket. This requires review. Some steps have been taken to ensure greater compliance with infection control. Service users now have improved linen bins. Money has been made available to purchase a new fridge and freezer. Hot food temperatures as previously required are now being taken and recorded. The Acting Manager has provided written guidelines with a good level of detail to further guide staff. A service user who is incontinent at night has been provided with a new mattress that is readily cleanable and a kyle sheet was seen on the bed. Red dissolvable laundry bags are now used to limit staff contact with soiled linen, which reduces the risk of cross contamination. The premises are clean and smelt fresh throughout. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 21 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): 35, 36 Training levels for staff have improved to better meet service users needs and to better protect them. Levels of supervision provided to staff have improved but are not sufficiently on target. EVIDENCE: The Inspector asked a service user whether staff know what they need to know in order to do their jobs properly. The service user reply was ‘yes they know me they do’. Fire training has been provided for staff in March and November 2005. Most staff have first aid, nutrition, food hygiene and infection control training with two needing to undertake both food hygiene and infection control training. . The Acting Manager said that anti racism is included in the equal opportunity training provided which she said 6 staff have done with 3 more to do in February 2006. However as this is an in house course there is no evidence of attendance. All staff have now received Adult Protection training. A training matrix is not in place but there is a print out provided by head office, which the Acting Manager said appropriately guides her to plan training for the team and individuals. Induction training is still not being provided to the appropriate standard but the Acting Manager said that since the last inspection the 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 22 provider has decided to provide induction through the Learning Disability Award Framework. Staff are beginning to receive structured and recorded supervision. Since the last inspection (5 month period) two staff have had one and some two supervision meetings with their manager. This is encouraging and the Acting Manager must strive to increase the momentum to meet the national minimum target of 6 sessions by July 2006 (7 months) The Inspector was not able to reassess recruitment practice as planned due to previous concerns because the file of the only new staff member recruited since the last inspection was not available on the premises. All files must be available for inspection. The file of a staff member supplied by an agency was briefly assessed. A Criminal Record Bureau check number indicated that a check had been undertaken but as this was undated there was no assurance that this check does not exceed 12 months old. There was also no confirmation from the agency for this staff member that a POVA check has been undertaken. The Acting Manager must ask the agency to review all checks in place for staff supplied to the home and to provide the home with updated and sufficiently detailed information. The Acting Manager feels that she is being provided with sufficient supernumerary hours to develop and manage the home but remains concerned about permanent vacancies being covered by agency staff. The Acting Manager’s concerns are exacerbated by the impending maternity leave of two senior staff members, with no contingency plan to replace them. Staffing levels were not assessed at this inspection but it was noted that the two night staff vacancies identified at the last inspection remain unfilled. The Inspector had sight of risk assessments in place to support pregnant staff and advised that they be reviewed given the identified behaviours of one service user who has recently punched someone in the stomach. The staff member sought medical advice on the day of inspection and the risk of this was confirmed. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 Quality Assurance systems have not yet been implemented, the home is not yet engaged in self-monitoring its performance. Service users safety is better but not fully assured. EVIDENCE: The Commission for Social Care Inspection has not at the time of writing received an application for registration of a manager of Havacre Lane. The Acting Manager has recently commenced the Registered Managers Award and hopes to complete it by December 2006. The provider has purchased a Quality Assurance tool since the last inspection. The purchase is very recent and has been installed on Managers computers and is now awaiting implementation. Some steps have been taken to meet improvements previously required to ensure safety. For example a detailed fire risk assessment is in place now which accounts for one service users smoking activity. The Acting Manager is 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 24 also following up action taken in response to accidents, which have been mostly minor. Fridge and freezer temperatures are being better monitored and those temperatures recorded are compliant but there are still gaps where temperatures are not being taken by staff. On a few occasions where recorded temperatures have not been compliant there is evidence that action has been taken which is progress since the last inspection. First aid training levels have improved with four staff having received training in 2005 with 2 more booked for February 2006. COSHH assessments remain insufficient as only data sheets are on the premises and a random sample of chemicals which were appropriately stored showed that Data sheets are not in place for all chemicals purchased and stored. Environmental Health have not been asked whether it is acceptable to regulate water temperature in the laundry and kitchen where this is required to safeguard service users who access those areas. Legionella checks remain not available to evidence the safety of water. The safety of the unsecured television in one service users bedroom requires review. Otherwise the premises and garden appeared to be free of obvious hazards. For additional evidence see text entered under Standard 24. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 2 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x x x 2 1 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 51 Havacre Lane Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x DS0000025011.V270836.R01.S.doc Version 5.0 Page 26 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. Care plans must include arrangements to meet assessed dietary needs. Timescale for action 31/12/05 2. YA6 15 17(1)(a) Sch 3.3m 31/01/06 3. YA6 15 Requirement first made and not met since October 2004. Advice provided by dietician 31/01/06 must be incorporated into the individuals care plan and must be reflected in the menu options. Residents and/ or their representative must sign the care plan to evidence participation and agreement. Requirements first made and not met since February 2004. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 27 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 Care plans must include all aspects of decision-making. This requirement was made and has not been met since March 29th 2005. A risk assessment is required for the use of the stairs for residents at risk. Requirements first made and not met since October 2004. There must be a greater correlation between activity plans based upon assessed need and evidenced outcomes for service users. 31/01/06 5. YA7 15 31/01/06 6. YA9 13(4)23 31/12/05 7 YA11 15 31/01/06 8 YA12 12(2) 12(3) 20 Requirement first made and not met since October 2004. 31/12/05 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. NOT MET - Prior to obtaining minibus Service users must be 31/01/06 enabled to be politically DS0000025011.V270836.R01.S.doc Version 5.0 Page 28 9 YA13 12(2) 12(3) 51 Havacre Lane 15 active and to vote should they wish to. Their wishes must be recorded. Requirement first made and not met since October 2004 and not assessed at December 2005. 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 The manager must ensure that residents are offered as a minimum annual health screening checks including vision, hearing and testicular screening. 10 YA16 5(b) 31/03/06 11 YA19 12,13 31/03/06 12 YA19 12, 13 At December 2005 hearing screening referral made. The Acting Manager must 31/12/05 review current health systems in place to ensure that service users are enabled to attend all their screening appointments regularly with no oversights. New Requirement at July 2005 and not assessed at December 2005. All medication errors must be reported to the Commission for Social Care Inspection. Requirements first made and not met since March 29th 2005 13 YA20 13(2) 06/12/05 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 29 Lactulose medication prescribed three times per day but not administered to the service user but must reviewed with the GP and the outcome recorded and advice followed. New Requirement at December 2005. A complaints procedure in a suitable format must be prominently displayed for Service Users. This requirement was made and has not been met since March 29th 2005. A policy on staff involvement in making service user wills must be available within the home. This requirement was made and has not been met since March 29th 2005. Behaviour plans must be adhered to. Not assessed at July 2005. Requirement first made October 2004 and not met at December 2005. The behaviour management Plan for service user D must be updated to reflect the change in behaviours. New Requirement at December 2005. The practice of charging service users for meals provided by the day centre must cease. Service users must be reimbursed for meals paid 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 30 14 YA22 22 31/03/06 15 YA23 13(6) 31/03/06 16 YA23 15 13(6) 31/12/05 17 YA23 13(6), 16(2)(i) 31/12/05 for in this way. Action taken must be confirmed in writing to the Commission for Social Care Inspection. The homes Adult Protection policy must be reviewed to include POVA guidance and omit reference to the right to instigate internal enquiries in the event of a pro longed enquiry New Requirement at December 2005. 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. Have readily available a planned program for the maintenance and renewal of the fabric and the decoration of the premises. Requirements made and not met since November 2002 Action must be planned to make good the following: Replace the grab rail in the first floor bathroom Redecorate the lounge and dining room area Redecorate the laundry 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 31 18 YA24 23(4) 31/12/05 19 YA24 13,23 31/03/05 20 YA24 23(2)(b)(d) 31/12/05 Repair damaged plaster work at foot of stairs The sharp broken tile on the bath in the first floor bathroom 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. 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. 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 first made and not met since November 2002. All staff files must fully DS0000025011.V270836.R01.S.doc 21 YA24 23 31/01/06 22 YA26 23 31/03/06 23 YA34 19 31/12/05 Page 32 51 Havacre Lane Version 5.0 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. 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 have not been met. Not assessed at December 2005 - file of only new staff member who worked for 2 days before leaving was not available on the premises. 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. Not Assessed at December 2005. To review the high use of DS0000025011.V270836.R01.S.doc 24 YA34 19 31/12/05 25 YA34 18 31/01/06 Page 33 51 Havacre Lane Version 5.0 agency staff and provide a written action plan to CSCI by 22/07/05 New Requirement at July 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 intended to improve performance in relation to recruitment. This must be forwarded to the Commission for Social Care Inspection by Friday 15th July 2005. This was issued as an immediate requirement at July 2005. Not assessed at December 2005 - new staff file not available The rota must be kept up to date and accurate (fully completed). Liquid paper must not be used to make amendments to the rota. New requirement at July 2005. Not Assessed at December 2005. 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 34 26 YA34 19, 9, 13(6) 31/12/05 27 YA34 Sch 3, 4. 31/12/05 28 YA34 19 The Acting Manager must ensure that recruitment checks in place for agency staff are reviewed and updated to ensure that all checks are in place and are no more than 12 months old. New Requirement at December 2005. 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. Staff must receive supervision a minimum of six times each in a 12month period. Period to assess July 2005 July 2006. New requirement at July 2005. 31/12/05 29 YA35 18(1)(a)18(1)(c) 31/12/05 30 YA36 18 12/07/06 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 35 31 YA37 9 Some progess at December 2005. The (second) Acting Manager must apply to the Commission for Social Care Inspection for Registration as manager. This requirement was made and has not been met since March 29th 2005. 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. The Provider must ensure that the homes policies for maintaining safe working practices are approved by the Environmental Health Department. This requirement was made and has not been met since March 29th 2005. (The acting manager is required to seek the advice of Environmental Health about appropriate water temperatures in the kitchen and laundry) This was an immediate requirement on March 29th 2005 and has not been met. 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. 31/01/05 32 YA39 24 31/03/06 33 YA42 13(4) 31/03/06 34 YA42 23(5) 31/12/05 35 YA42 13(4) 31/01/06 51 Havacre Lane DS0000025011.V270836.R01.S.doc Version 5.0 Page 36 36 YA42 13(3)(4) Staff must read and sign all COSHH assessments to evidence understanding. (A COSHH accident was identified at inspection March 2005) This requirement was first made and not met since February 2004 Fridge temperatures must be taken daily and records must be retained. Requirements first made and not met since February 2004. Manager (or delegate) must undertake the Intermediate Food Hygiene Award. Requirements first made and not met since February 2004. . Provide the CSCI with evidence to show that checks for Legionella has been carried out. Requirements first made and not met since November 2002. The safety of the unsecured television in the service users bedroom must be reviewed and action taken to minimise any risk identified. New Requirement at December 2005. The provider must ensure that fire systems including emergency lighting are tested regularly in house and that these tests and their outcomes are DS0000025011.V270836.R01.S.doc 28/02/06 37 YA42 13(3) 06/12/05 38 YA42 13(3) 18 31/03/06 39 YA42 18, 23 31/12/05 40 YA42 13(4) 23(2)(a) 13/12/05 41 YA42 23(4)C(i) 31/12/05 51 Havacre Lane Version 5.0 Page 37 recorded. New Requirement at December 2005. 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.V270836.R01.S.doc Version 5.0 Page 38 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.V270836.R01.S.doc Version 5.0 Page 39 - 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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