Inspection on 03/02/06 for 66 Dudley Street

This inspection was carried out on 3rd February 2006.

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

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

Other inspections for this house

66 Dudley Street 03/01/07

66 Dudley Street 25/09/06

66 Dudley Street 04/03/05

66 Dudley Street 17/11/04

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 66 Dudley Street West Bromwich West Midlands B67 9LU Lead Inspector Deborah Sharman Unannounced Inspection 3rd February 2006 09:15 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 66 Dudley Street Address West Bromwich West Midlands B67 9LU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 525 3900 londonroad@tiscali.co.uk Milbury Care Services Limited Wendy Dobson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th August 2005 Brief Description of the Service: 66 Dudley Street is a detached property, which has recently been purpose built to accommodate up to 6 people with Learning Disabilities/Autism.The property provides single occupancy rooms, all of which have en-suite shower, toilet and hand basin and are generous in size. Service users rooms are available on both floors and communal areas include a lounge, dining area, quiet room, and activity room. A domestic size and equipped kitchen is available and an adequate size laundry area. A Jacuzzi/spa bath is provided in the communal bathroom, and there are a further two toilets.The property is situated on a busy main road near to West Bromwich town centre and is easily accessible by public transport. The location enables service users to access local amenities and facilities and also neighbouring towns. There is a small drive to the front of the property and there is parking available on the road. There is good size a rear garden, which is well designed and level, and provides extra privacy and space for service users whilst making use of the area. The home offers intensive support to a group of individuals with a range of complex needs and strives to promote ordinary living principles and social inclusion. The service has its own transport. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced meaning the Provider, Manager and staff were notified in advance and were able to prepare. One Inspector carried out this inspection which began at 9.15 am and finished at 6.00pm. The plan for the inspection day was to assess those key Standards which were not assessed at the previous inspection. Documentation provided to the Commission for Social care Inspection by the home was also used to guide this inspection as were three comment cards provided about the home by relatives. There were not any previous requirements for improvement that corresponded to the Standards planned for assessment and it was therefore only planned to assess priority previous requirements. The Area Manager who was present for part of the day and the Homes Manager were however keen for progress to be assessed. Most previous requirements were therefore assessed but the consequence was that this extended the length of the inspection day. The Manager and Deputy Manager supported the inspection. A senior staff member was also involved in the afternoon. The Inspector was able to tour the environment, interview a support worker and meet most of the service users. It was possible to gain some feedback from a service user who demonstrated that he was keen to be involved. He indicated that he is happy, likes living at Dudley Street and enjoys going to the Day Centre. The Inspector assessed documentation, case tracked care provided to two service users and observed medication being administered. The outcome of this inspection is positive with good progress having been made and many previous requirements issued to ensure improvement having been deleted from this report. Managers, staff and service users made the Inspector very welcome and thanks are extended to them all for their cooperation throughout the inspection day. What the service does well: The premises are homely and fresh smelling. There is a welcoming happy and calm atmosphere within a home where service users behaviours can challenge. Medication was given out well by staff at the point of administration to the service user (although the Inspector expressed concern at the time it was given). There was good evidence that a service users change in health had been identified and responded to appropriately with support being given for him to attend a variety of outpatient tests over a number of months. The home works hard to communicate effectively with service users with many documents in pictorial form and some staff being able to communicate in sign language. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 6 Staff appear to be motivated and interaction with service users is positive and respectful. A staff member said ‘ I love it, the staff and service users are all lovely’. When asked what the home does well the staff member said the following to the Inspector: ‘I think the staff here are wonderful. I think they are really caring. They do promote independence and I think that as far as possible the needs of the service users are met’. The staff member spoke positively about the manager describing her as approachable and supportive whilst able to confront issues – ‘she has away of telling you if you have done something wrong’. Service users independence is promoted. For example on the day of inspection a service user had made his sandwiches for lunch. Two of three comment cards providing feedback from relatives were exceptionally positive about the service provided by Dudley Street. What has improved since the last inspection? There have been many improvements since the last inspection. Significant improvements have been made to the environment providing bettermaintained and homely premises for service users to live in that also better meet service users need. For example there is a new three piece suite in the lounge, broken tiling has been replaced in the communal bathroom which no longer has a musty odour, a missing kitchen drawer has been replaced and wardrobes have been secured to walls to reduce the risk of them toppling onto service users. In addition a service user whose preference is for a bath has been provided with a bath in his ensuite, which previously had only a shower. This better meets his needs and preferences and ensures that he no longer has to wait for the communal bath to be available. A quiet sensory room has been installed in an upstairs room for service users enjoyment and relaxation. Service users health is also better promoted as food cold storage is now compliant and being managed appropriately. Better control of water temperatures is also safeguarding service users from the risk of scalds more appropriately. Service users are also better protected by improved recruitment practice, an increase in staffing levels and in systems to make training more available. For example, Criminal Record Bureau checks have been obtained prior to employment for 3 new staff members. A staff member said that staffing levels are now ‘much better’ and that the staffing situation is no longer ‘horrendous’. Evidence shows that appropriate training is now being provided to staff in a timely manner. The Manager said that she feels better supported and there is evidence of some recent supervisions provided to her, which represents some improvement. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 7 What they could do better: Although care plans and care records are generally good, care plans contain some omissions and do not reflect needs assessed by the placing Social Worker. Some care records could improve to better evidence care provided, health outcomes being an example. The regularity of health screening must be made known in care plans and a system to alert staff to appointments due must be implemented as this information can be lost when records are archived. These risks missed appointments. Guidance in care plans must contain more detail in respect of agreed techniques for restraint of service users where and when required to support their own and others dignity and safety. Systems to support nutritional assessment could also improve. More information and better assessment is required to ensure that staff can identify if service users are at nutritional risk. Activities and outings are provided but systems to plan and monitor activity must be clarified. Also the range of activity offered could be extended to meet the assessed needs of service users. There was some evidence of service users having to wait for outings, which is not helpful for service users with autistic spectrum disorders. Staffing levels have generally improved but according to the homes own assessment of hours required has not improved sufficiently. The improved provision is making the home safer but compromising activity and spontaneity to some extent. Adult protection policies have not been reviewed to provide staff and managers with up to date comprehensive guidance and funding arrangements for holidays are not clear. It was not for example clear who was expected to pay staff accommodation costs when staff are accompanying and supporting service users on holiday. Policy and guidance is required to protect both staff and service users financial interests. A staff member felt that a second vehicle would enhance service users quality of life as some service users need to travel alone and this compromises choice and activities available to the others. The Manager said she believed plans are in place to provide a second vehicle. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 8 A previous requirement to improve quality assurance systems to help the service to monitor its own performance based upon the feedback and views of significant others has not improved. The manager has begun to devise questionnaires to seek third party views but these have not been actioned yet and the provider dos not appear to be taking a corporate lead on this significant area. 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. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 9 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 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Assessments are not used sufficiently to guide care planning. EVIDENCE: There have no new service users admitted to the home. There was however a copy of the placing Authorities Community Care Assessment / care plan on the service user’s file completed by the Social Worker at the time of admission. This had not been used to inform the service users plan of care within the home with there subsequently being omissions in the plan of care to meet his assessed need. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Improved care planning would better support service users assessed and changing needs. Service users are supported to make decisions about their lives with assistance as needs Service users are supported to take risks as part of an independent lifestyle but strategies are in place to minimise identified risks. EVIDENCE: Some care plans for some service users are better than others. The standard is therefore inconsistent. A psychology letter written in September 2005 to the home recognised as part of psychology input that staff may not have had access to a behaviour care plan / and or required support to understand it and action was taken as a result of this assessment. Guidance was in place for most aspects of personal care for one service users but not for a second service user. Health care plans state that screening must be ‘regular’ with no guidance as to how regular. Where health-screening frequencies are stated there is some contradictions. For example there is on one care plan reference 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 12 to annual and 2 yearly optical tests. Behaviour management care plans are positive and recognise precipitating factors. In the event of the need for physical restraint the guidance is not sufficient with ‘team control’ advised. This does not recognise any specific needs of service users based on health, disability or gender differences. There is a key worker system in place to support service users. Evidence of care plans being reviewed formally with minutes of review meetings being available. There is good guidance within care plans on ‘supporting decision making’ and good detail given for each service user on their preferences and how staff can best support them to make decisions e.g. by using demonstrations, praise and gestures. Care records are also completed in such a way as to evidence some decisions made by service users and responded to by staff. One service user has an advocate. The provider is the appointee for 3 service users. The provider is receiving money on behalf of these service users made payable to the provider. This money is then being paid in to the company business account. Although systems appear to be in place to safeguard service users interests this practice is contrary to the regulations and should be reviewed. Guidance is in place to provide direction in the event of a service user going missing. Risk assessments are in place in respect of service users. Discussion with a staff member showed that she was aware of risk assessments in place, the nature of the controls to reduce risk and her responsibility in relation to risk assessment. Service users can display behaviour that challenges. There have been some incidents as a result in the community which have prompted complaints and required resolution. It is to the staffs and management credit that following such incidents they are committed to ensuring ongoing social inclusion for service users. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 16, 17 EVIDENCE: Service users attend day centres and college and options for one service user are being explored currently. Where service users are not able to attend college the home is currently receiving activity support in house from a local college. This provides weekly craft and games activities for service users in their own home and also supports them working towards identified individual goals which is monitored by mentoring visits by staff at the college. This provides service users with enjoyment, the opportunity to develop skills and contact with community facilities with a view to moving towards attending college in the future. Records show that service users are supported to access the community. The range of integration was a little limited to a small range of evidenced activity and a greater range would have been good to see e.g. cinema, theatre, bowling for example. However those activities undertaken with service users although limited in range are those enjoyed by service users and reflect the need for consistency as a result of service users autism. One service user has joined a local gym and this is an example of very good social inclusion. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 14 Activity levels have improved since staffing levels have improved. All spoken to felt that seventh staff member would support the better provision of activity for service users and there was some recorded evidence of service users having to wait to undertake requested activity. This does not support positive behaviour management for service users with autism. A complaint has been received from a neighbour which although not yet resolved has received a response. Service users wishes in respect of voting or any restrictions, which would limit this opportunity, are not accounted for in the plans of care. Full compliance with the Standard addressing service users rights and responsibilities was observed during the course of the inspection day. It was pleasing to see a staff member supporting a service user to open his mail. Pictorial menus which offer meals three times daily are produced weekly and there was evidence that they are adhered to. On the day of inspection a service user had been prompted to make his own sandwiches for lunch and he took his sandwich to eat it in a place of his choosing. Service users weights are monitored and records of weights are kept. Systems are not sufficiently in place to assess whether weights taken are healthy or placing service users at risk. For example, although one service user had maintained his weight of 12 stone throughout 2005 he had lost 13 pound in weight the previous year. It is not known whether this weight loss or whether his current weight is healthy and safe. It was agreed that the system adopted to assess nutritional risk was not adequate as it appeared to be a tool for older people and seemed inappropriate for younger adults. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 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): 18, 19, 20 Outcomes for service users personal care is good with all service users being supported to be well dressed and groomed. Some written guidance could improve to promote consistency in approach which accords with service user preference. Health care is generally good with there being good evidence that changes in health are noted and responded to well. Some routine health screening is less well evidenced and will be better supported if documentation is reviewed. Medication is generally well managed with there being some areas identified for further improvement EVIDENCE: Outcomes for service users personal care is good with all service users being well groomed and dressed in a way which reflects their wishes and personalities. All service users are mobile and therefore moving and handling and associated equipment is not required. Care planning has been referred to earlier and in respect of personal care requires more detail to support consistency of approach by staff for some service users. Gender issues during the provision of personal care are considered in care plans promoting the privacy, dignity and respecting the wishes of service users. Service users 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 16 preferred routines are set out well providing appropriate guidance for staff. Records show that with respect to rising and retiring times service users free will is respected. The staff group reflects the ethnic background of the area local to the home. The home networks well with services external to the home to ensure that service users have access to a range of professional help and support. Psychologists, speech therapists, occupational therapists have all provided support and parents are involved in formal reviews of the care provided. Generally there is good evidence of service users being supported to attend health appointments with staff recording outcomes of appointments well. There is also good evidence that the changing health needs of one resident have been recognised, reported and that he has subsequently been supported to attend a wide range of investigatory outpatient appointments. There is also good evidence that he has been supported to keep his six month medication reviews with the Consultant Psychiatrist. There are however some gaps and duplications in the system and it was not possible to find evidence that the service user had been supported to attend the full range of health screening such as Well Man, optician and hearing teats. It also appeared that he had missed his 4-month podiatry appointment due in August 2005. This had been complicated by the move of the clinic and although the Senior staff member said that she had attempted to contact the clinic to ensure an appointment she was advised to always record such intervention to demonstrate action taken to evidence the duty of care. Regular archiving of records with the current system compromises continuity of health care. For example there was no record on the current file of when the service user had last had an optician appointment and with the confusion over whether these should be yearly or two yearly risks this aspect of care being overlooked. The Manager said that the home receives medical services from a very supportive GP. Medication is generally well managed with there being a few areas identified for further improvement. Practices in relation to ordering, receiving and storage of medication is good. There were no gaps in the medication administration records. Medication prescribed as ‘as required’ is being appropriately recorded when given with the time and dose administered recorded. Guidelines are in place for the administration of ‘as required’ medication and the use of homely remedies have been approved in writing by the GP. Times of administration pose some concern with one service user as a result of choice regularly receiving her medications at times which differ from that prescribed. This is of concern to the Doctor involved but the home is noting the times of administration, has brought the issue to the Doctors attention and a review meeting is organised with the Community Nurse to discuss the issues on 8th February. A service user taken out on the day of inspection did not take his medication with him and did not return in time to take it at the prescribed time, taking it some 3 hours later. The Inspector observed the medication being administered and other than the time of administration, the medication was administered to the service user well. The 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 17 Manager said that this is not usual practice but perusal of the medication procedure found that there is no guidance specific to this situation. Discussion with the Manager showed that there are further implications too as the care staff escorting the service user may not be approved to administer medication at the required time whilst out in the community. The home is not keeping copies of prescriptions and whilst this is not regulated it is considered to be good practice. However prescriptions should be retained in the event of entries being made in handwriting on the Medication Administration Record to evidence the reason for this. Assurances could not be given that the medication training provided to the home is accredited training. In addition staff are administering medication alone without a witness system to support them. Whilst there is a system in place for the manager to assess the ongoing competence of staff to administer medication this had last been undertaken in 2003 and an update is required. Quarterly support visits by the supplying pharmacist are well evidenced. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not assessed but discussion with a staff member showed that she had a good understanding of what abuse is and her role in preventing it. She also showed a good knowledge of required action in the event of becoming aware of a protection concern. The manager has obtained a copy of local Adult Protection procedures since the last inspection and has been advised at this inspection to obtain a copy of the British Institute of Learning Disabilities guidelines on Physical Intervention. Complaints are being better recorded. It was a requirement from the previous inspection to notify the Commission for Social care Inspection on each occasion that a service user is physically restrained. The Manager feels that the 12 occasions have been notified but verification shows that the Commission for Social care Inspection has received 5. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 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): EVIDENCE: These Standards were not assessed at this inspection but progress since the last inspection is referred to in the Summary section at the beginning of this report. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 The home is working towards ensuring that the staff team is competent and qualified. EVIDENCE: This inspection has seen improved staff training outcomes for Dudley Street although more staff need to do more special knowledge skills training given the need of the service users at the home. Forty percent of staff have the required minimum NVQ qualification with well managed certificates being available to evidence this. This is short of the 50 target set nationally for 2005 but 60 of staff either have or are working towards this qualification. All staff have done Challenging Behaviour training (NVCI) but not enough staff have done Epilepsy Awareness training (13 out of 24) and Autism training (9 out of 24. The Deputy Manager said more had done this but records had not been updated). New staff had been supported to complete an induction in house to TOPPS standard but had not yet started Learning Disability Award Framework induction Training within the required time frame. TOPSS training is provided in the absence of LDAFF availability at the time of appointment but is not fully meeting the Standard and is duplicating staff time and effort. Two new staff members recently appointed are under 18 years old. Managers were aware of guidelines that restrict the practice of staff who are less than 18 and 21 years old and written guidelines advocating no involvement in the provision of personal care were seen. Risk assessments which address all areas have not been carried out however to address medication administration, escorting 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 21 service users, working with equipment including kitchen equipment etc. Assessment of the rota shows that these two new and inexperienced staff work on different shifts to ensure staffing skills are appropriately balanced on each shift. Staff members spoken to demonstrated good knowledge of risk assessments, care plans, adult protection and behaviour management and had undertaken 8 training curses in the previous 12 months. Where staff have required support to understand behaviour management however this has been evidenced by involving supporting Psychologists in a team meeting in September 2005, which it seems that some staff benefited from more than others. Managers and staff spoke positively of improved staffing levels with 6 staff being provided on each shift except for night shifts. Assessment of recent rotas showed this to be the case with the exception of none peak times. It has been a previous requirement for the home to notify the Commission when its staffing levels are not appropriate and this requirement remains to ensure that the ongoing situation can continue to be monitored. The Commission was notified in both October and November 2005 of several occasions when staffing levels had dipped to 3 or 4 staff being on duty primarily as a result of sickness which is not acceptable and is unsafe. Contingency plans must be sufficiently adequate to ensure adequate staffing at all times. The situation will continue to be monitored. Whilst noting the improvement it remains a concern that the home is not providing the care hours that it has assessed it requires. The home budgets for 718 care hours per week including night staff and the Managers total hours. If Management hours (17) are debited from hours used the total shows that 697 care hours were provided. The home has assessed that 781 care hours are required leaving a deficit of 84 care hours which if provided would enhance activity provision. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not assessed at this inspection. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 23 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 2 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 X 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X X X X X X X X 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 24 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 13(6) Requirement Care plans must establish individualised procedures for service users likely to be aggressive or cause harm or self harm and must describe restrictions on freedom (e.g. restraint techniques) agreed by a multi disciplinary team based upon service users needs, disabilities, physical health gender etc. (This is as opposed to current general guidance which states ‘use team control’) 2 YA6 12, 13 New Requirement at Feb 06. Health Care plans must state the regularity / required frequency of health screening. Health monitoring record systems must be reviewed to ensure accessible accurate monitoring of health provision. To review with staff the use of terms ‘good’ and ‘bad’ behaviour (as seen in care records at Feb 06 New Requirement at Feb 06 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 25 Timescale for action 30/04/06 30/04/06 3 YA7 20(1)(a)(b) The Registered person must not pay money belonging to any service user into a bank account unless the account is in the name of the service user to which the money belongs; and the account is not used by the registered person in connection with the carrying on or management of the care home. Current systems must therefore be reviewed with action taken confirmed in writing to the Commission for Social care Inspection. New Requirement at February 2006. The provider must ensure that a policy is in place which clarifies responsibilities for holiday expenditure. ‘Staffing’ costs met by the organisation must be defined e.g. who funds staff hourly rates, staff expenses, staff meals, staff accomodation costs arising from the holiday. New Requirement at February 2006. Service users nutritional risk must be assessed using a reliable assessment tool (with action taken where required to meet nutritional need) Sufficient information must be available to ensure that the level of nutritional risk is known to staff. New Requirement at February 2006. 30/04/06 4 YA14 13(6) 30/04/06 5 YA17 13(4) 31/03/06 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 26 6 YA18 15 All care plans must provide guidance on all aspects of personal care based upon service users preferences to ensure a consistent approach. New Requirement at February 2006. To ensure that systems are in place to support service users taking medication at the prescribed time e.g particularly when going out in to the community. New Requirement at February 2006. To confirm in writing to the Commission for Social Care Inspection whether the current medication training provider is accredited. The Manager must update the inhouse assessments of staff compentency to administer medication. Copies of presciptions must be held when MAR sheets are completed by hand New Requirement at February 2006. The home’s Adult Protection policy requires review to ensure it complies with the expectations of Local Authority guidelines. New Requirement at August 2005 – not met at Feb 06 All restraints employed must be notified in writing to the Commission for Social care Inspection (without delay) 31/03/06 7 YA20 13(2) 28/02/06 8 YA20 13(2) 30/04/06 9 YA23 13(6) 30/04/06 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 27 10 YA24 23(2) New Requirement at August 2005 – not met at February 2006 (5 of 12 notifications received) – next incident and retrospective incidents not notified. A written maintenance and renewal programme must be developed. New Requirement at August 2005 – not assessed at Feb 06 Full risk assessments must be carried out for each staff member under the age of 18 years old with all hazards identified and control measures put in place. New Requirement at Feb 06 The rota must distinguish between when the Manager is providing care and management hours. New Requirement at Feb 06 To notify the Commission for Social Care Inspection as a Regulation 37 notice on any occasion when morning (8a.m. – 10a.m.) staffing levels drop below 5 staff and below 6 staff for the time period 10.00 a.m. – 10.00 p.m – Requirement first made August 2005 met but ongoing requirement for subsequent occasions. To inform the Commissioning Departments of Social Services who contract with the home (Staffordshire, Sandwell, Wolverhampton and Worcestershire) of the reduction in budgeted care hours and action planned. 30/04/06 11 YA32 18, 13(4) 28/02/06 12 YA33 18, 17 28/02/06 13 YA33 18(1)(a) 28/02/06 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 28 Social Services must be informed by Monday 15th August 2005. New Requirements at August 2005 – not assessed at Feb 2006. 14 YA34 18 The Provider must explain in writing to the Commission for Social care Inspection why it is not providing 781 care hours assessed as required. The provider must include what action is being taken to address this. New Requirement at February 2006. To ensure that all induction (within 6 weeks of commencement) and foundation training (within 6 months of commencement) is delivered, and is in accordance with guidance issued by the Training Organisation Personal Social Services (TOPSS) – TOPSS done in house in timescale but not LDAFF at Feb 06. 2. To identify and access relevant training for staff in the use of British Sign language (BSL). The home should aim for at least one person on duty at all times who have the skills to use BSL – not assessed at Feb 06 3. To ensure all staff are provided with awareness training with regards to the Autism and the range of Autistic Spectrum Disorders –at Aug 05 7 staff not done. 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 29 31/03/06 15 YA35 18 30/04/06 At Feb 05 9 out of 24 staff not done. 16 YA35 18(1)(a)(c), Staff to have completed (Infection Control Training) by 31.10.05 – date not met at Feb 06 but progress evidenced. 20 out of 24 staff completed with 4 booked for Feb 06. 30/04/06 17 YA37 18, 24 Second Immediate Requirement at August 2005 The registered manager of 66 31/08/06 Dudley St, must receive regular, formal, and appropriate supervision meetings with a line manager from `Milbury`. Requirement outstanding since March 2005. At Feb 06 some progress – two supervisions dated Sept and Oct 2005. Mimimum of Six to have been completed by 31.8.06 The quality assurance tool must be reviewed. New Requirement at August 2005 Not met at Feb 06 but some in house initiatives in process. 18 YA39 24 31/08/06 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA15 Good Practice Recommendations The manager should review the way in which contact with friends and families is recorded to facilitate monitoring. Care plans should state the specific arrangements for contact with family and friends i.e. twice per week on Mondays and Fridays as opposed to ‘regular’ To consider implementing a witness system during the administration of medication. To consider retaining copies of all prescriptions. The manager was advised that due to the volume of information held with regards to the care and risk management strategies in place, all current documentation should be checked, to ensure it is the most up to date and is dated and signed by the staff and where possible the service user or their representative. 2 YA20 3 YA41 66 Dudley Street DS0000054828.V281719.R01.S.doc Version 5.1 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: 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. 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