Inspection on 16/01/07 for 59 Whitehorse Road

This inspection was carried out on 16th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

59 Whitehorse Road 31/08/07

59 Whitehorse Road 17/01/06

59 Whitehorse Road 21/06/05

59 Whitehorse Road 01/03/05

59 Whitehorse Road 21/09/04

59 Whitehorse Road 02/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Whitehorse Road, 59 59 Whitehorse Road Brownhills Walsall West Midlands WS8 7PE Lead Inspector Lesley Webb Key Unannounced Inspection 16th January 2007 09:00 Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitehorse Road, 59 Address 59 Whitehorse Road Brownhills Walsall West Midlands WS8 7PE 01543 361478 F/P01543 361478 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) Mrs Jacqueline Anne Bernard Dorothy Jones Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: 59 Whitehorse Road provides residential accommodation and personal care for up to six younger adults with learning disabilities. The home is located on the outskirts of Brownhills close to Cannock Chase, a public house and local shops. All bedrooms are single occupancy; there is a large lounge, dining area, well equipped kitchen and separate laundry facilities. No bedrooms have en-suite facilities. It is a single storey building with parking to the front and a large patio area to the rear. The home has ramps and grab rails making it easily accessible. The home also provides its own transport. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by one inspector with the home being given no prior notice. During the visit time was spent formally interviewing staff, examining records and observing care practices before giving feedback about the inspection to the senior on duty. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking three individuals care provided at the home. For example the people chosen have differing communication and care needs and consist of male and female. No relatives were present during the inspection. All service users have varying learning disabilities so formal discussions were not appropriate. Additional time was spent indirectly observing care practices, interactions between service users and staff and formally interviewing staff in order to assess needs being met and quality of service. The registered manager was not present during the inspection, with feedback on the inspection findings given to the senior on shift. Pre-inspection information was requested by the Commission for Social Care Inspection prior to the visit but this was not returned by the requested date neither were any service user questionnaires. Therefore information from this source could not be used when forming judgements on the quality of service provision. Information was not available within the home regarding the range of fees charged for living at the home, with no one present during the inspection being able to supply this information. The inspector would like to thank both service users and staff for their cooperation and assistance during time spent at the home. What the service does well: There have been no new admissions to the home since the last inspection. However policies and procedures are in place along with needs assessment documentation that if implemented will ensure prospective service users needs are assessed in order that the home can be sure that it is suitable for the person. Staff have adequate understanding of supporting service users to make decisions. When asked how people who live at the home are supported to made decisions responses include, “we have service user meetings, where we ask if happy, what they want to do, and try to meet their needs. Staff meetings as well, every service user has a key worker, service users usually have a word with key worker who puts forward to manager. If they want anything new, go out somewhere, holidays, magazines, sweets or something new in bedroom we help sort this for them”. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 6 Staff have a good understanding of supporting service users to maintain relationships with comments made including, “we keep a verbal route open between us, the service users and their families. Some service users go home on visits which we help to arrange, parents go to reviews, we keep them updated on the needs of their relative”. As in previous visits the inspector witnessed staff offering personal support to residents, respecting their privacy and dignity. All staff that were interviewed demonstrated knowledge of the preferences of individuals and were able to give explanations on how these preferences are met. Generally health records are good ensuring that health needs are appropriately managed by the home. As in previous inspections the home is well maintained and comfortable. There is a large lounge/dining area that is decorated and furnished in a homely way and a well-stocked kitchen with all appropriate facilities. All bedrooms are tastefully decorated and appropriate bathing and toilet facilities are located near to all bedrooms. On the day of inspection the premises were comfortable, bright and free from offensive odours, providing service users with a comfortable place to live. Levels of staff either holding or in the process of completing a national vocational qualification are good. Many of the staff that work at the home have done so for several years building relationships with service users appropriate to gender, age and personal interests. Observations and discussions with staff demonstrate that the staff group is made up of individuals from various backgrounds, with differing skills and experiences that complement the service users group presently living at the home. What has improved since the last inspection? What they could do better: Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 7 The home must review and amend it management of service users personal finances. This must include ensuring service users do not fund from personal monies any items that are the responsibility of the home, reimbursing for purchasing of furniture, bedding and towels and demonstrating that if service users wish to purchase items of furniture above the allocated budget assigned by the home, that the home still contributes the said amount. The home must also ensure that if service users wish to purchase items of furniture above the allocated budget, that this is agreed within a multidisciplinary forum. Work must also be undertaken by the home to ensure the adult protection procedure complies with the local authority guidelines. Improvements must be made in these areas to ensure the home is meeting its contractual obligations. Improvements to some staff training are required to ensure people are suitably qualified to support people living at the home. This includes demonstrating that all staff undertake a fire evacuation drill at least annually, arranging for staff to undertake infection control training and ensuring staff hold up to date certificates in first aid, moving and handling, food hygiene and fire. During the inspection the inspector found many documents and policies stored in the office that were either no longer applicable, out of date and/or that did not comply with relevant legislation. An audit of all records and policies must take place to ensure practices are appropriate and comply with legislation. Minor amendments are also required to some medication records to ensure the safety of everyone living at the home. Finally care plans and risk assessments must be developed further to contain specific information for staff. Without this the home cannot be confident that all the identified needs of service users are being met. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 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 Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is currently meeting the assessed needs of people living there. Policies and procedures if implemented in full would ensure that prospective service users needs are assessed prior to admission; ensuring needs are identified and catered for. EVIDENCE: There have been no new admissions to the home since the last inspection. However policies and procedures are in place along with needs assessment documentation that if implemented will ensure prospective service users needs are assessed in order that the home can be sure that it is suitable for the person. All current service users files contain needs assessments completed by the placing authority. The home has a Statement of Purpose and Service User Guide, which everyone is given on admission to the home. These documents are also given to prospective service users and their representatives when visiting the home to look at its suitability. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 10 As in the previous inspection all the staff that were interviewed were able to give detailed knowledge of service users needs and records viewed by the inspector confirmed that service users needs are assessed appropriately prior to admission. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans identify individual’s needs but require expanding to contain specific aims and goals in order that staff have sufficient information to meet service users needs. Although improved, further work is required to ensure risk assessments contain sufficient information to inform staff and protect service users. Staff understand the importance of supporting service users to make decisions about their lives. EVIDENCE: The home has introduced essential lifestyle plans (a form of person centred planning) for all service users that have been completed with service users, staff and other interested parties. Upon inspection of these the inspector found that they varied in terms of content and completion. It was also noted that one plan contained no pictures or symbols as aids to communication apart Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 12 from an emblem on the front cover. When asking staff about their understanding of person centred planning none were able to demonstrate knowledge of this, with responses including, “they are about general history of a person”. No staff was able to explain the principles and values that form the basis of this form of care planning. Individual plans of care were viewed, all of which detailed health, personal and social care needs, non however contained specific aims and goals or breakdowns of tasks in order that goals can be achieved. Discussions with staff and looking at records confirmed that plans are reviewed every month with the involvement of service users, key workers and the manager. Staff have adequate understanding of supporting service users to make decisions. When asked how people who live at the home are supported to made decisions responses include, “we have service user meetings, where we ask if happy, what they want to do, and try to meet their needs. Staff meetings as well, every service user has a key worker, service users usually have a word with key worker who puts forward to manager. If they want anything new, go out somewhere, holidays, magazines, sweets or something new in bedroom we help sort this for them”. When examining the records of the service user meetings the inspector found these occur on a regular basis but that the records currently do no evidence action taken to address requests or reasons if these are not carried out. It was also noted that since the last inspection the majority of service users have had new bedroom furniture, all of which is the same with no evidence of individual choices to reflect personalities. Two previous requirements relating to risk assessments are part met. Risk assessments are in place for service users but further work is still required to ensure these contain sufficient detail and are in place for all identified needs. When examining the assessments on some of the service users files the inspector found that these give very basic information regarding fire, bathing, medication, outings, food and aggressive behaviour and do not include a breakdown of tasks for staff, or details of amount of support service user require. For example one assessment for aggressive behaviour states as existing controls ‘will carry her drink staff make sure of temp and may hit others on head as she passes’ action required ‘staff made aware of support’ and ‘staff ware of supervision needed’. In the main risk assessments read as an overview rather than a detailed assessment. The manual handling assessments were found to be better with an immediate assessment that indicates a level of risk that then allows for a further detailed assessment if required. It was also noted that various formats are currently in place, some that allow for greater detail to be recorded than others and that in many instances these have been stapled together. It is recommended that information from these various sources be combined into one document. When talking to staff they demonstrated knowledge of supporting service users with regards to risk taking. For example one person stated, “we should be Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 13 aware if doing anything risky and inform them, give guidance if going to hurt selves or dangerous”. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to make choices about their life style. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: As in previous inspections all staff that were interviewed gave examples of activities that service users participate in which include shopping for personal items, clubs, pubs and attendance at various day centres. Activity charts detail a variety of in-house and external activities including regular contact with relatives. It was noted that on the day of inspection the activities for one service user did not occur as detailed in their planner. When discussing this with the senior on duty the inspector was informed that this was because the manager was on annual leave and that additional staff had not been allocated to ensure that two carers remain in the home whilst activities take place. For Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 15 the whole of the inspection all but two of the service users were attending daycentres. The two service users at home were observed sitting with staff, watching various DVDS and spending part of day in bedrooms listening to music. Also as in previous visits the inspector found an abundance of evidence through discussions, interviews and records that service users are helped to maintain family links. For example the home takes one service user home to visit her mother several times a month, another service user goes to visit parents every fortnight, staff send Christmas and birthday cards on behalf of service users to relatives and keep relatives informed by telephone of important matters such as hospital appointments (giving families the opportunity to attend if they wish). Staff have a good understanding of supporting service users to maintain relationships with comments made including, “we keep a verbal route open between us, the service users and their families. Some service users go home on visits which we help to arrange, parents go to reviews, we keep them updated on the needs of their relative”. The inspector witnessed staff knocking on bedroom doors before entering to ensure privacy and respecting individuals needs to be alone. All service users bedroom doors are lockable with over-ride safety devices. No service user has a key to the front door of the home, however risk assessments have been implemented relating to this practice. Files sampled by the inspector found parental consent for staff to open service user mail on their behalf. A number of the residents were spoken to and confirmed that the food offered in the home is good and that they are offered daily choices including hot and cold meals, deserts and puddings. There is currently a four weekly menu in place. This states for breakfast a choice of cereals, toast and pure orange juice and a cooked breakfast on Saturday. Lunch is ‘residents choice’ and then there is the evening meal (this gives only one choice). It is recommended that advice be sought from an appropriate professional regarding menu planning as the current menus only detail one meal with salad and one fish choice. Individual meals taken are currently being recorded on a note pad. When examining the inspector found that not all meals are being recorded and in some instance meals taken do not reflect those on the menu. It must be noted that when examining the contents of the kitchen an abundance of fresh, frozen and tinned food items were in place all of which were of a high quality. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the health needs of service users are well met, with evidence of good multi disciplinary working taking place. Personal support in this home is offered in such a way as to promote and protect service users privacy, dignity and independence. Minor improvements to some medication practices will offer further protection to service users. EVIDENCE: As in previous visits the inspector witnessed staff offering personal support to residents, respecting their privacy and dignity. All staff that were interviewed demonstrated knowledge of the preferences of individuals and were able to give explanations on how these preferences are met. All previous requirements relating to healthcare are now met. All service user files contained comprehensive healthcare records including evidence that hearing tests have been arranged. Generally health records are good and sufficient evidence that health needs appropriately managed by the home. Initial health check assessments have been completed for all service users in Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 17 order that appropriate monitoring of needs takes place. Records sampled by the inspector demonstrate that service users receive healthcare checks for medication, chiropody, dentists and opticians. The home uses a monitored dosage system for the administration and management of medication. Generally the records for medication entering, being administered and leaving the home were found to be appropriate, with only minor improvements required. Some PRN medication was found not be recorded on the medication administration sheets, a prescribed cream was not dated when opened and a handwritten medication administration sheet gave instructions of administration as ‘as directed’. It was also noted that two staff sign the medication administration records. It is recommended that either this practice ceases or the second signature be recorded on a separate sheet as it could indicate that medication has been administered twice and also it does not ensure sole responsibility for administration. The inspector was informed that since the last inspection the majority of staff have undertaken accredited medication training and are awaiting certification. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints and protection policies and procedures are in place but need reviewing to ensure service users are protected in full. There is some evidence that service users feel their views are listened to and acted upon however improvements to records will evidence this further. EVIDENCE: Complaints and protection policies require reviewing and amending as they contain either conflicting or out of date information. For example the complaints policy in the homes policy folder gives information about the National Care Standards Commission including the address of an office that is now closed. An adult protection policy instructs to refer to Dudley APU but not any other local authorities despite people living and being placed by Walsall social services and makes no reference to notify the Commission for Social Care Inspection. A second policy was found that states it was reviewed July 2005 but contains different and in parts conflicting information and the prevention of violence and aggression policy (reviewed Dec 2005 by the manager) makes reference to regional directors and operations managers when none are in place. Three different restraint policies were also found, again all of which contain different information and guidance. The complaints folder was viewed with no complaints recorded to have been made since the last inspection. There is some evidence that venues are in place where service users can raise issues but further work is recommended to Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 19 evidence that issues raised are acted upon. For example service user meetings occur on a regular basis where people have the opportunity to raise issues. Currently the records of these do not evidence action taken to address issues and outcomes. Staff have knowledge of complaints and protection. When asked how they support service users to raise concerns and protect them from abuse responses included, “look at behaviour, body language, get to know when happy or not. Report to manager or senior” and “report everything to the manager”. When examining the records maintained for the management of service users finances the inspector found that service users have purchased furniture from their own personal monies. This is against the contents of contracts of residency. The inspector instructed that the home has a responsibility to fund furniture and either must reimburse the full amounts or at the very least make a contribution appropriate to budgets allocated. If the home can demonstrate that service users requested items above allocated budgets for replacement of furniture it would not be unreasonable for the outstanding balance to be funded by the individual however in this case the home must be able to demonstrate this was agreed within a multi-disciplinary forum. It was also noted that some service users have also purchased bedding and towels, this again is the responsibility of the home and reimbursement must be made accordingly. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good, providing service users with a comfortable place to live. EVIDENCE: As in previous inspections the home is well maintained and comfortable. There is a large lounge/dining area that is decorated and furnished in a homely way and a well-stocked kitchen with all appropriate facilities. All bedrooms are tastefully decorated and appropriate bathing and toilet facilities are located near to all bedrooms. On the day of inspection the premises were comfortable, bright and free from offensive odours. The home has a separate laundry room with washing, drying and sluicing facilities. Since the last inspection a hand washing sink, paper towels and liquid soap have been provided, meeting a previous requirement. Written policies and procedures are in place for the control of infection that includes Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 21 the safe handling and disposal of waste, dealing with spillages, provision of protective clothing and hand washing. Infection control training is still required for staff, with the senior stating that the proprietor is going to book this in the near future. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally staff in the home are trained, skilled and in sufficient numbers to support the people who live there. EVIDENCE: Levels of staff either holding or in the process of completing a national vocational qualification are good. The senior on duty explained that everyone apart from the newest member of staff will hold either a level 2 or 3 qualification, with many just awaiting certificates. Many of the staff that work at the home have done so for several years building relationships with service users appropriate to gender, age and personal interests. Observations and discussions with staff demonstrated that the staff group is made up of individuals from various backgrounds, with differing skills and experiences that complement the service users group presently living at the home. Generally staffing ratios meet the needs of service users however consideration must be given to additional cover when the registered manager Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 23 is on annual leave. As mentioned earlier in this report a service user was not able to participate in external activities on the day of inspection due to no additional staff being allocated whilst the manager was on leave. Normally there are two staff on duty during the day and early evening, with additional staff allocated on several evenings in order that service users can attend various offsite activities. During the night there is a wake night person and a ‘sleep-in’. In addition to this an emergency on call system is in place. The home does not employ separate kitchen or domestic staff, with the care staff undertaking duties in these areas. Records viewed confirm that regular staff meetings take place where all aspects of the home are discussed. It is recommended that these be expanded to detail agreed action points, who will be responsible for carrying out actions and agreed dates. Recruitment and selection procedures are good. The inspector sampled four staff files, all of which contained the required documentation as listed in Schedules 4 and 6 of the Care Homes Regulations 2001. In addition, it was pleasing to find evidence that service users are supported and involved in the recruitment and selection of staff. One previous requirement for staff to undertake learning disability award framework accredited training is now met with the majority of people working at the home having undertaken training in this area. Other areas of training that staff have received certification for include equal opportunities, epilepsy, behaviour management and adult protection. It is recommended that further guidance be given in person centred planning as no staff demonstrated adequate understanding in this area (see standard 6 of this report). Although there is no training and development plan for the home or individual assessments for staff the inspector could find no evidence of this having a detrimental effect on training provision for staff. All records viewed demonstrate that the manager monitors training needs and that in the main staff are suitably qualified. The inspector was unable to validate if a previous requirement instructing that the manager receives supervision is met due to no one being present at the inspection that had information regarding this. This requirement will therefore remain in place. All staff files sampled contained evidence that they receive supervision but further work is required to ensure the amount meets national minimum standards. All files did however contain evidence that staff receive an annual appraisal in addition to one to one supervisions. Staff that were spoken to all stated they are happy with the amount of support they receive, with comments including, “receive support from manager and other members of staff, we work as a team, makes it better for everyone and service users are happy, we are like a close family”. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality monitoring includes seeking the views of people living at the home and ensures aims and objectives can be measured. Further work is required to ensure that all practices within the home promote and safeguard the health, safety and welfare of people living and working there. EVIDENCE: The registered manager was not present during this inspection, with a senior undertaking management responsibilities in her absence. The registered manager has been in position at the home for several years and holds qualifications appropriate for her position. All staff that were spoken to confirmed that the registered manager is approachable and open, communicating a sense of direction to everyone. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 25 As in previous inspections the home has a good quality assurance system that it has devised itself based on the needs of the home and service provided. Records demonstrated that most areas of Standard 39 are being met, with regular evaluation taking place by the manager that links the development of the service to the needs of the service users. These include Service user questionnaires, family questionnaires and stakeholder surveys. An annual report is also completed by the registered manager. It is recommended that staff receive guidance in understanding what quality assurance is and why it is important as no staff who were spoken to were able to give an explanation of what this is. As mentioned in previous sections of this report many policies and procedures require reviewing and amending in order that they comply with relevant legislation. When looking at health and safety the inspector was concerned to find within the policy folder health and safety information that gave examples of manual handling that are no longer recommended. These included instructions for the ‘Australian lift’, ‘picking a service user up on staffs back’ and the ‘drunks lift’. An abundance of folders, documents and other information is currently being stored in the office, much of which is no longer applicable, out of date or no longer relevant. An audit must take place with records no longer required archived as they have the potential to give wrong information or cause confusion. Written evidence verifies that gas, electrical wiring, equipment and water services are maintained appropriately and within the approved timescales. External contractors complete analysis of the water for compliance with Legionella along with the home carrying out its own monthly water temperature checks. COSHH data sheets are in place for products used within the home along with assessments of risk (meeting a previous requirement). Training records confirm that staff hold certificates for first aid, moving and handling and food hygiene, however some of this were found to be out of date when examined. Records confirm that regular fire evacuation drills take place involving the service user and staff, however the records do not detail the names of staff involved in these resulting in the inspector unable to verify if all staff employed at the home are involved in this process. Also records state that fire training took place October 2006 for all staff but again this record does not specify which staff and up to date certificates were not in place on any staff file sampled. The senior was instructed that priority must be given to addressing this to ensure the safety of everyone living at the home. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 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 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 2 2 2 X Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 27 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Care plans must be in place for all identified needs that contain specific aims and goals for individuals. Timescale for action 31/03/07 2 YA9 13(4) Essential lifestyle plans must be completed in full and be in a format accessible to service users. Comprehensive risk assessments 31/03/07 must be completed for all service users based in their individual capabilities – part met. Requirement originally made January 2006. Risk assessments must be completed for any identified needs contained with plans of care – part met. Requirement originally made January 2006. Records must be maintained of all meals eaten by service users. All PRN medication must be recorded on the medication administration records. That ‘as directed’ instructions must be clarified with the 3 4 YA17 YA20 Sch 4 (13) 13(2) 01/02/07 01/02/07 Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 28 5 6 YA23 YA23 13(6) 13(6) 7 YA23 13(6) general practitioner, with clear instructions obtained and recorded on the medication administration records. The adult protection procedure must comply with the local authority guidelines. Service users must not fund from personal monies any items that are the responsibility of the home to provide. Service users must be reimbursed for purchasing furniture, bedding and towels. If service users wish to purchase items of furniture above the allocated budget assigned by the home for these items, that the home still contributes the said amount. If service users wish to purchase items of furniture above the allocated budget assigned by the home, that this is agreed within a multidisciplinary forum. All staff must undertake infection control training – not met. Requirement originally made January 2006. That the manager receives regular, formal supervision, with records maintained – part met. Requirement originally made January 2006. That all staff receive at least six formal supervision sessions per year, with records maintained. That all policies and procedures are reviewed and comply with relevant legislation and good practice guidelines. Particular attention must be given to: The complaints policy, 31/03/07 17/01/07 01/02/07 8 YA30 13(3) 31/03/07 9 YA36 18(2)(a) 31/03/07 10 11 YA36 YA40 18(2)(a) 17 12(1) 31/03/07 31/03/07 Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 29 The adult protection policy, The prevention of violence and aggression policy, The restraint policy, The management of service users monies policy; and 12 YA41 17 12(1) 13(4)(5) 18(1) 23(4) The manual handling policy. An audit of all records maintain in the home must take place with records no longer applicable being archived. All staff must hold up to date certificates in first aid, moving and handling, food hygiene and fire. The home must be able to demonstrate that all staff undertakes a fire evacuation drill at least annually. 31/03/07 13 YA42 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA6 YA7 YA9 YA17 YA20 Good Practice Recommendations Staff should receive guidance to understand the principles of person centred planning. The home should evidence action take to address requests made by service users in meetings have been actioned or reasons if these are not carried out. That risk assessments for the same area of risk are audited and information maintained in one document. That advice is sought regarding menu planning and providing nutritionally balanced meals. That the staff who sign as second signature for the administration of medication do this on a separate record DS0000038819.V326436.R01.S.doc Version 5.2 Page 30 Whitehorse Road, 59 6 7 8 9 YA22 YA33 YA36 YA39 to that of the medication administration record. That records of any issues raised by service users include actions taken to investigate and outcome. That additional staff are allocated in order that service users can participate in planned activities when the registered manager is on annual leave. That the minutes of staff meetings be expanded to detail agreed action points, who will be responsible for carrying out actions and agreed dates. That staff receive guidance in understanding what quality assurance is and why it is important. Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whitehorse Road, 59 DS0000038819.V326436.R01.S.doc Version 5.2 Page 32 - 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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