Inspection on 03/01/07 for 66 Dudley Street

This inspection was carried out on 3rd 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

66 Dudley Street 25/09/06

66 Dudley Street 03/02/06

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 Lesley Webb Key Unannounced Inspection 3 & 4th January 2007. 09:30 rd 66 Dudley Street DS0000054828.V323836.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 66 Dudley Street DS0000054828.V323836.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. 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 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 http/www.milburycare.com/home.html Milbury Care Services Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection September 2006. Brief Description of the Service: 66 Dudley Street is a detached property, which has 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 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.V323836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this inspection over two days 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 acting manager. 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 consist of both male and female, from differing cultural backgrounds, with varying communication and care needs. One relative of a service user was present during the inspection, who praised the home and the service provided. The home is registered to provide long term care for people by the reason of learning disabilities and autism. Discussions with service users living at the home were not appropriate. Therefore observation of behaviours was undertaken in order to form judgements on care provision. A number of records and documents were also examined as well as case tracking. Fees charged for living at the home range from £1425.00 to £2841.75. The inspector would like to thank everyone for his or her co-operation and assistance shown during the visit, where the atmosphere within the home was welcoming and friendly. What the service does well: Admissions and assessment policies and documents, care plans and health care records within the home are comprehensive, ensuring the home can be confident of meetings the needs of service users. It is also pleasing to find that all care plans contain specific aims and goals based on each person individual capabilities. This promotes a person centred approach to care. When interviewing staff all demonstrated good knowledge of the contents of care plans and their roles as key workers. For example one person stated, “as key worker I help to buy clothes, toiletries, furnishing rooms in their own way, take them to shopping centre so they can choose own items. It’s their choice. Care plans are important because every individual is different, it’s a way of communicating with them, as they have different needs, they are in place to make sure we can meet their needs and they are happy”. All service users living at the home have differing communication needs. Again all staff demonstrated understanding of involving service users in making decisions despite potential communication barriers. For example one person explained, “one service user is non verbal but can use sign language, so I have learnt some basic signs so can communicate, senior can communicate deeper, 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 6 we are having training so we can communicate” while another stated, “give different choices, get photos of different activities, and show them so they can choose from pictures. Some service users will grab you and point to kitchen so we then ask what they want, show different things from cupboard”. As in previous inspections an abundance of evidence is maintained within the home that demonstrates service users lead full and active lives. Activity timetables detail events including personal shopping, living skills, leisure activities, college and free time. All, also include at lease two or three choices of activity that service users can participate in. Health and safety records demonstrate that appropriate monitoring is taking place. These include assessments for Legionella, audits of the building and health and safety risk assessments. What has improved since the last inspection? Nearly all of the requirements identified in previous inspections have been addressed or partly addressed, demonstrating the manager’s commitment to providing a quality service. Care plans have been reviewed to ensure that all information is up to date and reflects service users current needs. Also care plans have been established with individualised procedures for service users likely to be aggressive or cause harm or self harm, describing restrictions on freedom (e.g. restraint techniques). These now need to be agreed by a multi disciplinary team to meet this requirement in full. Also the manager has made arrangement for two service users to be involved in the collection of their benefits resulting in their personal monies no longer being paid into the company account, has developed a policy which clarifies responsibilities for holiday expenditure and ceased the practice of service users funding furniture items and the cost of meals (although reimbursement is still required). All of these improvements offer greater protection to service users. Improvements to health care have also occurred. Service users nutritional risk is now assessed using a reliable assessment tool, medical advice has been sought for a service user who had lost a significant amount of weight and the accident procedure has been reviewed and amended. Action has also been taken to seek approval from the general practitioner regarding the administration of PRN medication and update in house assessments of staff competency to administer medication have been completed. These improvements ensure service users health needs are being appropriately managed. With regards to the environment the manager has implemented a maintenance and renewal programme that includes specific target dates for replacement of specific items of furniture identified as damaged, decoration of each room, refitting of the kitchen and window cleaning (however at the date of inspection no work had commenced). Until such time as work is completed the home is not as comfortable as it could be for people living there. 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 7 Other areas where improvements have occurred include altering the layout of the duty rota, ensuring all new staff undertake a full induction and the provision of autism awareness training. These improvements ensure staff are suitably qualified and in sufficient numbers to care for people living at the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 66 Dudley Street DS0000054828.V323836.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 66 Dudley Street DS0000054828.V323836.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 good. This judgement has been made using available evidence including a visit to this service. Admissions and assessment policies and documents are comprehensive, ensuring the home can be confident of meetings the needs of prospective service users. EVIDENCE: The home is fully occupied and there have been no new admissions since 2003. The admissions policy and documentation was viewed. Both these documents are comprehensive and if adhered to should ensure any prospective service users needs are appropriately assessed, resulting in the home being confident of meeting individual’s needs. There are no outstanding requirements in relation to these Standards. Conversations with staff and observation of care practices indicate that the home attempts to meet the needs of service users. For example staff were seen using sign language in order to communicate with a service user and others were observed assisting service users as per their plans of care. 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning and risk assessment processes are clear and consistent, providing staff with the necessary information in order that service users needs can be met. Generally service users are supported to make decisions for themselves to maximise their independence. EVIDENCE: As at the last inspection care plans within the home are detailed and comprehensive. All those sampled contained specific aims and goals based on each persons individual capabilities. Individual plans include those for nutritional needs, personal care, bathing, hair washing, dental care, clothing, family contact, out in the community, preferred times of rising and going to bed, support with professionals such as occupational therapists, speech and language, life skills, intellectual needs, decision making, medical needs, social interaction and culture. It was also pleasing to find for each individual plan of care personal guidelines are in place to support and give additional information relating to the implementation of the care plan. Risk assessment have been 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 11 completed that work in conjunction with both the care plan and personal guidelines. Again these are detailed and appropriate. Many of the service users living at the home have behaviours that can challenge. Individual procedures for those likely to be aggressive or cause harm or self-harm are in place that describe any restrictions on freedom. Although detailed (including the use of pictures), the home is still required to ensure their agreement for use by a multi disciplinary team. Since the last inspection all care plans have been reviewed, meeting a previous requirement. When interviewing staff all demonstrated good knowledge of the contents of care plans and their roles as key workers. For example one person stated, “as key worker I help to buy clothes, toiletries, furnishing rooms in their own way, take them to shopping centre so they can choose own items. It’s their choice. Care plans are important because every individual is different, it’s a way of communicating with them, as they have different needs, they are in place to make sure we can meet their needs and they are happy”. However when discussing person centred planning staff were less knowledgeable in this area, with the inspector recommending that further guidance and training be provided. In addition to the care plans staff complete daily records and monthly summaries that give an overview of events including activities, professional treatment, behaviours and home visits. These are then used by the manager to monitor that the contents of care plans are being adhered to. The inspector recommends that additional guidance be given to some staff as the contents of the monthly summaries varies in terms of content and context. All service users living at the home have differing communication needs. This area was explored by the inspector when interviewing staff, all of whom demonstrated understanding of involving service users in making decisions despite potential communication barriers. For example one person explained, “one service user is non verbal but can use sign language, so I have learnt some basic signs so can communicate, senior can communicate deeper, we are having training so we can communicate” while another stated, “give different choices, get photos of different activities, and show them so they can choose from pictures. Some service users will grab you and point to kitchen so we then ask what they want, show different things from cupboard”. Practices observed confirm staff attempt to encourage service users to make decisions and support them to understand different choices. 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at this home are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: As in previous inspections an abundance of evidence is maintained within the home that demonstrates service users lead full and active lives. Records include detailed and comprehensive care plans and risk assessments relating community activities, further education and social contacts. Activity timetables detail events including personal shopping, living skills, leisure activities, college and free time. All also include at lease two or three choices of activity that service users can participate in. Actual activities that service user participate in are then recorded in the daily records. When examining the records the inspector at times found it difficult to track if the contents of planners and care 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 13 plans have been adhered to. This was discussed with the manager who agreed that monitoring systems could be improved. Since the last inspection action has been taken to address requirements identified in previous inspections. The manager has developed a comprehensive policy that clarifies responsibilities for holiday expenditures, including funding of staff meals, accommodation and transport. Records of meals indicate that service users receive a range of food items suitable for their individual needs. Work has also been completed to ensure everyone’s nutritional needs are assessed and a service user identified in the previous inspection has now received appropriate medical intervention. Of the twenty-six staff employed at the home eight have undertaken nutritional awareness training, with the manager stating arrangements are being made for others to undertake this in the near future. The need for this training was further re-enforced when examining a service users nutritional documentation as staff had ceased recording this persons monthly weight as indicated as a requirement of the nutritional assessment, despite this person losing a stone in weight over a twelve month period. This was discussed with the manager, who again agreed to take action. 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and person care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Minor amendments to some medication practices will offer further protection to people living at the home. EVIDENCE: Since the last inspection the manager has reviewed procedures for night staff to follow in the event of an accident, addressing a previous requirement. The new procedure now includes instructions to refer to each service users care plans; health documentation and risk assessments to ensure action is take based on each persons individual needs. Generally the health needs of service users are well managed. Comprehensive records are maintained for each individual for medication, health appointments and medical conditions including epilepsy. All service users have health action plans in place for conditions including epilepsy, mental health, vision, chiropody, occupational therapy and psychology. When examining these the inspector found that all state review dates as ‘ongoing’. This was discussed with the manager who 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 15 agreed to amend so that specific dates for review are in place that will allow for effective monitoring. It was also noted that on one persons file a document for breast examination is in place. When exploring this the inspector was informed that the service user in question is instructed to examine their breasts. The inspector questioned this, as the service user has complex learning disabilities that have the potential to affect their understanding. It is recommended that advice be sought from the community nurse regarding this, with the possibility of an annual examination being included in the yearly health check this person receives. Work has also been undertaken to address medication requirements identified in the previous inspection. The home has written to the general practitioner to seek guidance and approval for PRN medication and practices of medication administration when service users are away from the home. As yet the home is still awaiting a response and until this is in place requirements relating to these areas will remain in place. Medication policies, storage and records were examined. Generally these appear appropriate with only minor amendments required. The home uses the Boots medication dispensing system, with four senior staff employed at the home responsible for the administration of medication. All records relating to medication being booked into and returned to the supplying pharmacy, controlled drugs and fridge line medication appear appropriate. It was noted that some medication instructions state ‘as directed’. The inspector explained that any medication prescriptions must have clear and detailed instructions and that the home must not accept any prescriptions without this information. The home was also instructed to clearly identify any PRN medication on the medication administration records. Three recommendations relating to medication are also made. Firstly that a stock count of all PRN medication be maintained, secondly that homely remedies be stored separately from prescribed medication and thirdly that a record be maintained of the temperature within the medication cabinet. Improvements in these areas will enhance systems already in place and offer greater protection to people. 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally people who live at the home have access to a robust, effective complaints procedure, are protected from abuse and have their rights protected. EVIDENCE: Detailed complaints policies are in place for both informal and formal complaints. The complaints procedure is also available in widget easy read format with a copy on each service users file examined. It was noted by the inspector that the easy read format explains that complainants have right to refer complaints to the Commission for Social Care Inspection (CSCI) at any stage (as per the National Minimum Standards for Younger Adults) but that the formal procedure states refer to CSCI on conclusion of investigation by the home if not satisfied. There has been one complaint since the last inspection, made by the parent of a service user regarding staff on duty who appeared to lack training to support and safeguard service users. This complaint was upheld. Records relating to the investigation and actions required to rectify the situation appear appropriate apart from the submission of a regulation 37 notification to CSCI. Due to communication barriers the inspector was unable to ascertain service users views on complaint processes and therefore spent additional time interviewing staff in order to assess their knowledge in this area. The majority demonstrated knowledge and understanding in this area, explaining their responsibilities to support service users. For example one person explained, “Look for facial expressions, changes in behaviour, report 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 17 any concerns to the manager”. The inspector recommends this subject be discussed further in staff meetings and supervision to further enhance staff understanding. Action has been taken to address all but one requirement identified in previous inspections relating to protection. The system for paying service user money into a corporate account has ceased, service users are no longer funding furniture that is the responsibility of the home or paying for meals. Further work to reimburse service users for these items is still required before these requirements are met in full. The homes adult protection policy still requires reviewing to ensure it complies with the expectations of local authority guidelines. This was discussed with the manager who agreed to draft an internal procedure until such time as Millbury have amended and agreed a corporate procedure. The physical intervention policy was also viewed and appears appropriate although it was noted that this states to be reviewed September 2006 and no evidence of this occurring could be found. It was also noted that a document ‘crisis management risk assessment form’ accompanies the policy that is currently not used by the home. This was discussed with manager who agreed to implement to further enhance recording systems currently in place. All staff that were interviewed demonstrated some knowledge of adult protection, however it is recommended that further guidance be offered in this area particularly in relation to the whistle blowing procedure and only one of the four members of staff was able to explain what this was. 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who live there to live in an environment that encourages independence. Although some steps have been taken to plan for future maintenance, the outstanding matters in this area result in people living in a home that in some parts is not well maintained and comfortable. EVIDENCE: Since the last inspection the manage has introduced a written maintenance and renewal programme that includes a schedule for replacement of specific items of furniture identified as damaged, decoration of each room and refitting of the kitchen (addressing a previous requirement). However at the time of inspection no work had started to address deficits in the environment, with many areas of the building appearing worn and/or damaged. Areas that require attention include improving the lighting in the office, cleaning the stained carpets in the dining room and hallways, replacing worn bedding, repairing damaged shelving in the bathroom, cleaning and/or painting all communal doorways if stains cannot be removed and decorating all communal 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 19 areas. It was also noted when touring the building that a service users door is wedged open using a chair. This was seen to occur during both days of the inspection. The inspector instructed that an appropriate self closing devise be fitted to the door that is linked to the fire alarm system rather than the use of a chair that has the potential to place the service user at risk if there were to be a fire. Infection control systems were also examined. The home has a small separate laundry that has all required equipment. When discussing cleaning schedules the manager explained that cleaning duties are allocated on a daily basis. The inspector strongly recommends that the home review its cleaning schedules as old food items were seen in one service users bedroom and a strong odour was emanating from another service users bedroom. Improvements to the numbers of staff requiring infection control training are also required as currently fourteen of the twenty six staff have up to date certificates in this area. 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is adequate. 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: Four of the five requirements identified in previous inspection relating to staffing and training have now been met. Staffing levels are now in the main being appropriately maintained, duty rosters have been amended that now detail what staff actually undertake shifts and all new staff now receive induction training. Also all staff have either received or are booked on autism awareness training. The manager has also attempted to access relevant training for staff in the use of British Sign Language, but at the time of this inspection was still awaiting confirmation of this. In the main all staff personnel files sampled contained the required documentation as detailed in the Care Homes Regulations 2001. These include job descriptions; contracts of employment, medical declarations, forms of identification, evidence of enhance criminal bureau disclosures and references. It was however noted that application forms for some staff did not detail a full 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 21 employment history, with no written explanations for gaps in employment and that some references did not appear to give appropriate information in order to judge candidates suitability for the role they were applying for. This was discussed with the area manager who was present during the second day of inspection who explained the organisation was currently in the process of amending its application form in order to address these matters. The inspector recommends that when applicants have had short times of employment or have never worked in the care profession additional references be sought in order that the home can be confident of their suitability for the role they are applying for and to safeguard people living at the home. A training schedule has recently been introduced to the home that include the provision of moving and handling, fire, introduction to CSCI, non-violent crisis intervention, learning disability award framework, equal opportunities, medication induction, health and safety, induction and national vocation qualification training. In addition to this a training and development plan is also in place along with individual training needs analysis for staff (however the need reviewing to bring them up to date). When looking at individual staff certificates many were found to be missing. The manager stated that some staff have attended courses but still not received certificates. The inspector explained that certificates should be the only item (as apposed to attendance lists) that are used to validate, as these are the only items that confirm not only attendance but also that person passed an exam or was deemed sufficiently competent by the trainer. Certificates were in place for some staff for non-violent crisis intervention, adult protection, epilepsy awareness; positive approaches to communication and national vocational qualification level two. The inspector instructed that work be undertaken to ensure certificates are maintained within the home to demonstrate sufficient numbers of staff have received appropriate training in order to care for people living at the home and to meet their individual needs. 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the management and administration of the home is based on openness and respect, with effective quality assurance systems that allow the home to measure if it meeting its aims and objectives. EVIDENCE: The acting manager is in the process of completing her application for registration and on the day of inspection made a commitment to submit the application by the end of January 2007. Throughout the inspection the manager demonstrated understanding of her role and responsibilities. A previous requirement to ensure the manager receives appropriate supervision 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 23 and support is now met, with evidence that she has received several formal supervision sessions. A schedule is in place to ensure these continue. Quality assurance systems were assessed and appear appropriate with only minor amendments required. This includes service user and relative’s surveys, monthly audits and a development plan. At the time of inspection the home was waiting for responses to the relatives surveys. The inspector instructed that surveys must be sent to professionals such as social workers and health care professionals and that all responses should be analysed and incorporated into the annual development plan for the home (currently this only includes outcomes from other audits and is not based on the views of service users and their representatives). It was however pleasing to find that the development plan completed by the manager is based on the National Minimum Standards for Younger Adults, allowing the home to measure its service against required legislation. Also when interviewing staff all were able to explain why quality assurance is important, for example one person stated, “improving the quality of the house, giving the best care and service”. All previous requirements relating to health and safety are either met in full or part met. Water temperatures are now being appropriately monitored, and food analysis has started to be recorded (however further work is still required in this area). Risk assessments and a written protocol are also now in place for staff that undertaken decorating duties. When assessing health and safety management in relation to fire the inspector found that monthly fire drills take place for staff and service users, however none have occurred after 5pm. The inspector recommends this be amended in order that an assessment of the situation can be made if a fire were to occur of an evening, when less staff are on duty (nights). It was also noted that nine of the twenty-six staff employed at the home have not undertaken a fire drill in a twelve-month period, two of which are night staff who are sometimes on duty at the same time. The inspector instructed that remedial action be taken immediately regarding this. Other health and safety records were viewed and demonstrate that appropriate monitoring is taking place. These include assessments for Legionella, audits of the building and health and safety risk assessments. An abundance of COSHH data sheets and risk assessments were found to be in place (over one hundred) however when sampling products currently in use in the home non for available. It is strongly recommended that an audit of this documentation take place with information no longer required removed and new information obtained for products now in use. As mentioned in standard 35 of this report an abundance of documentation is maintained regarding staff training, however many certificates used to validate staffs competency are missing. In relation to health and safety training certificates are in place for eleven staff for first aid, twenty-two staff for food hygiene, twenty-six staff for moving and handling and five staff for health and safety. 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X 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 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 25 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 13(6) Requirement Timescale for action 01/03/07 2 YA20 13(2) 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 – part met. Requirement originally made February 2006. To ensure that systems are in 01/03/07 place to support service users taking medication at the prescribed time e.g. particularly when going out in to the community. (At September 06 procedure completed. The Manager must obtain the supplying pharmacists advise about double dispensing referred to within procedure) – part met. Requirement originally made February 2006. Directions for the administration of PRN medication (particularly 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 26 In respect of medication prescribed to modify behaviour) must be obtained from the prescriber – part met. Requirement originally made September 2006. The home must clarify any ‘as directed’ instructions with the general practitioner, obtaining clear instructions for use. All PRN medication must be clearly identified on medication administration records. The home’s Adult Protection policy requires review to ensure it complies with the expectations of Local Authority guidelines – not met. Requirement originally made August 2005. Service user 1 must be reimbursed for the payment made for the double bed – not met. Requirement originally made September 2006. Service users must not fund the cost of meals and must be refunded where this has been the case – part met. Requirement originally made September 2006. That action is taken to address deficits in the environment. That this includes addressing: Poor lighting in the office, Decorating communal areas, Cleaning stained carpets, Replacing worn bedding, Repairing damaged shelving, 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 27 3 YA23 13(6) 01/03/07 4 YA24 16, 23 01/03/07 Cleaning and/or painting communal doorways, Fitting self-closing devises to bedroom doors. To identify and access relevant 01/03/07 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 – part met. Requirement originally made February 2005. That certificates are maintained within the home that demonstrate sufficient numbers of staff are employed that are suitably qualified. That the results of surveys are analysed with the findings incorporated into the annual development plan for the home. HACCPS must be carried out as per Food Safety Inspection requirement Jan 06 with further advice sought from Environmental Health Food Safety Department if required – part met. Requirement originally made September 2006. That all staff participate in a fire drill at least annually. That certificates are maintained to demonstrate staff have received training in first aid, health and safety and fire. 6 YA35 18 7 YA39 24 01/03/07 8 YA42 13(3)13(4) 01/03/07 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 28 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 6 7 Refer to Standard YA6 YA6 YA6 YA17 YA19 YA19 YA20 Good Practice Recommendations That staff receive further training and guidance in person centred planning. That staff receive additional guidance in the completion of monthly summaries. That monitoring systems for activities be improved in order to demonstrate that contents of care plans are being adhered to. That all staff receive further guidance and training in nutritional awareness and recordings relating to this. That health care risk assessment review dates be specific rather than state ‘ongoing’. That advice is sought from the community nurse regarding self-examination of breasts for service users who may lack capacity to understand. That a stock count of all PRN medication be maintained. That homely remedies be stored separately from prescribed medication. That a record be maintained of the temperature within the medication cabinet. That staff receive further guidance in relation to supporting service users with communication difficulties to raise concerns or complaints. That staff receive further guidance in relation to the whistle blowing procedure. That cleaning schedules are reviewed. When applicants have had short times of employment or have never worked in the care profession that additional references be sought. That fire drills take place at times when reduced staff numbers are in place e.g. at night. That an audit of COSHH records be undertaken. 8 9 10 11 12 13 YA22 YA23 YA30 YA34 YA42 YA42 66 Dudley Street DS0000054828.V323836.R01.S.doc Version 5.2 Page 29 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. 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