Inspection on 28/11/05 for 68 Bescot Road

This inspection was carried out on 28th November 2005.

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

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

Other inspections for this house

68 Bescot Road 29/04/09

68 Bescot Road 30/04/08

68 Bescot Road 10/10/07

68 Bescot Road 02/10/06

68 Bescot Road 05/08/05

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 68 Bescot Road 68 Bescot Road Walsall West Midlands WS2 9AE Lead Inspector Mr Patrick Wright Announced Inspection 28th November 2005 10:00 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 68 Bescot Road Address 68 Bescot Road Walsall West Midlands WS2 9AE 01922 648758 0121 525 8492 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) Lonsdale (Midlands) Limited Jane Anderson Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 68 Bescot Road is a care home, which is owned and managed by Lonsdale Midlands Ltd. The home offers nursing care and personal support to up to eight individuals with a learning disability with health and/or complex social care needs, plus degrees of behavioural challenge. The service is divided into two areas. A respite unit is situated on the ground floor and a `long term` unit on the first floor. A passenger lift is available. The two units have the same layout and comprise of four single occupancy rooms, (some with en-suite shower facilities) a shared bathroom and two separate toilets, lounge, dining room, and kitchen. The two units operate independently of each other. The external area of the home comprises of a car park at the front and small rear garden. Entrances and exits are ramped to ensure access by those with mobility difficulties. The home aims to provide its residents with a secure, relaxed and homely environment in which their care, well being and comfort are of prime importance. This is stated to be achieved through a programme of activities designed to encourage mental alertness, self-esteem, social interaction with other residents and with recognition of core values which are fundamental to the philosophy of the home. The core values being Privacy, Dignity, Rights, Independence, choice, and fulfilment. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over 7 hours, and was a statutory announced inspection, of which the home had approximately six to eight weeks notice. The purpose of the inspection was to assess progress and compliance in meeting the National Minimum Standards and towards addressing items identified at the last inspection. A range of inspection methods was used to make judgements and obtain evidence, which included discussion with the Registered Manager and a tour of the premises. A number of records and documents were also examined. Other information was gathered prior to the inspection, which included the pre-inspection questionnaire and feedback from relatives’ surveys. There are five service users currently living at 68 Bescot Rd. The home is registered to provide personal and nursing care for adults with learning and other complex needs. All of the service users were involved in various community activities during the inspection. One service user was spoken with before he left the home to go to day care. The inspection was conducted with the co-operation of the Manager and the discussions and atmosphere throughout the inspection was constructive. What the service does well: Relatives and friends are encouraged to maintain links with the service users and are welcome to visit at any reasonable time, and the company complaints procedure is readily available should anyone wish to use it. There is a clear complaints procedure for service users and relatives, thereby ensuring individuals views and concerns are listened to and acted upon. Menus are prepared on a four weekly basis, and the menu sheet examined indicates that an alternative choice for each main meal is on offer. The menus are prepared based on the known likes/dislikes of the service users. Evidence was available that special diets, (for health or cultural reasons) can be provided at the home. The variety of foods being served appears to offer a balanced diet. The staff team manage to maintain the cleanliness of the home and address the fabric of the building to a satisfactory standard given the wear and tear it endures from the active group who live there. The client group are positively encouraged and assisted to undertake a variety of activities in addition to their main and regular routines. Staff support service users to become part of the community as much as possible. The home regularly accesses the local community to meet the social and educational interests of the occupants of the home. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 6 The Registered Manager is experienced and qualified to run the home and meet its stated aims and objectives. One relative commented; “Since my son arrived at Bescot Rd, the staff have been marvellous with him, no problems with them at all.no complaints” One service user was asked how he liked the home and if he was being looked after well. He replied “Yeah..Its great” What has improved since the last inspection? What they could do better: The home does not provide a staff team of whom 50 are qualified to at least NVQ level 2. The Registered Manager needs to be more proactive in planning to meet targets set by the `Skills for Care` organisation and CSCI. Recruitment practice lacks continuity and potentially places people who use the service at risk. The sample of staff files examined indicated there was a lack of consistency in terms of the recruitment practice. Evidence of training and personal development for the staff is lacking and there are omissions in demonstrating a robust audit trail is in place. There is insufficient certificated evidence to confirm that staff have been provided with the relevant training, or induction and probationary/supervision meetings. There was some difficulty in examining certain records which the Registered Manager stated had been mislaid. These were with regard to specific service contracts and records of staff being involved in fire safety practices. All of the required service contracts and testing certificates should be collated and the information available. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 7 Other issues needing attention relate to evidencing choice is being offered, decision making, demonstrating flexible daily routines, exploring `needs led` day care activities, and quality assurance. The manager is well aware of the areas where the home needs to show improvement, and is confident and committed to meeting the shortfalls, which have been identified. 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. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A EVIDENCE: None of the standards form this section were assessed at this inspection. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The management and staff cannot fully demonstrate that service users are consulted on and participate in all aspects of the home. However, there are indicators this is being explored. EVIDENCE: As part of the ongoing assessment process the staff are trying to facilitate choices for service users by exploring the use of signing, pictorial and different forms of communication. This is still at an early stage and the Registered Manager is attempting to raise the awareness of staff about how to evidence this process. The entries in daily notes do not show how staff are respecting service users rights to make decisions. Similarly, the Registered Manager must consider strategies for demonstrating how individual choices have been made and why, when such choices are made by staff. Some examples were identified in personal files and daily notes, but the Registered Manager was advised of the need to expand on this, and for staff to be made more aware of their role in demonstrating how service users make day to day decisions affecting their lives. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 11 The Registered Manager is not an agent or appointee for any of the service users, but the home does manage some of the individuals personal allowances. The service users take some responsibility for their own money, but it is held in safekeeping when not requested or being utilised. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15,16 and 17 Staff are helping service users to find appropriate educational facilities and training and take part in peer and culturally valued activities. However, this needs to progress to demonstrate that all relevant options are being explored. Staff support service users to maintain relationships inside and outside the home. The meals in this home are acceptable with evidence that service users are offered appropriate meals or alternatives. EVIDENCE: 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 13 Through discussion with the Registered Manager, the staff team are trying to ensure that day care offered is stimulating and meaningful. With service users assessed needs in mind, staff are attempting to identify suitable educational facilities which can cater for some of the service users at the home, and are striving to ensure a range of varied and valued activities are offered. The Registered Manager must ensure that structured activity/plans are in place for this group, and demonstrate that other opportunities for day care and education have been researched. It is therefore advised that structured activity/plans continue to be implemented and regularly evaluated. Service users who choose to, or that are unable to access appropriate facilities, must be enabled to take part in valued and fulfilling activities at the home, with records of consultation and outcomes available. Service users who use the short stay facility continue to access their usual day care placements or activities. The home has implemented a visiting policy/statement and does not restrict visitors at reasonable times. This has been brought to the attention of the service users relatives /friends, initially through an open house event/coffee morning for prospective service users and their families. Since then the information is circulated as needed. 68 Bescot Road welcomes relatives and friends of service users and to the home and they are encouraged to be involved. The home provides lounges/communal areas, plus service users rooms, where visitors can have privacy, (and for service users preferring a quiet area). Contact with relatives varies between service users, but links are maintained to whatever degree compatible for both parties. All but one of the service users continue to maintain close links with their families and friends and this is respected and encouraged by staff. There is a visitor’s book in the front porch that all visitors are asked to sign, which is good practice and complies with fire safety. The Registered Manager stated that the home attempts to maintain the privacy dignity and choice of service users, which is monitored through observation of practice and via staff supervision sessions. Information is gathered for respite clients through the Community Learning Disability Teams and from records being maintained during the period of time the individuals stay at the home. Privacy locks are fitted to service users rooms, which can be overridden by a master key in the event of an emergency. The use of keys by service users who accept the offer must be the subject of a risk assessment. Service users are not offered keys to the front door, as the home is rarely unattended, and due to suggested security risks has a coded door lock fitted. Service users do not have unrestricted access to the home. There are coded door locks on certain areas. Any personal mail for service users that is received at the home should be opened only with the prior agreement of the individual or their relative/representative. The home to needs to consider how it can ensure it is able to demonstrate that the service is as flexible as possible in terms of general routines of daily living, 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 14 and if there are any restrictions of rights, how this has been agreed and is being managed. Menus are prepared on a four weekly basis, and the menu sheet examined indicates that an alternative choice for each main meal is on offer. The menus prepared are based on the known likes/dislikes of the service users. To support the claim that service users preferences and likes have been incorporated into the menus, the home is intending to implement service user meetings, initially for the `long stay` unit and keep records of decisions made. In addition, staff intend to offer the service users assistance with choosing, in the form of a pictorial menu. Evidence was available that special diets, (for health or cultural reasons) can be provided at the home. The variety of foods being served appears to offer a balanced diet. Records of the core temperature of cooked foods being served are not being maintained. The Registered Manager stated that these had been mislaid recently. Fridge and freezer temperatures are being checked and recorded. It was not possible to evidence that all staff have received training in basic food hygiene. Staff must not be involved in the preparation and cooking of food until they have been provided with this training. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home is not yet able to demonstrate that service users receive personal support in the way they prefer. However, early indicators suggest positive outcomes are being identified. EVIDENCE: Through examination of records and discussion with the Registered Manager, there was evidence to suggest that personal support is carried out sensitively and maximises residents’ independence. Service users are being encouraged to make their preferences clearly known as to how they want their care to be delivered and by whom. The home operates a higher than average staffing ratio, which may involve nominated support staff working closely with one service user for parts of the day. A key worker system is to be implemented to assist with the information gathering process and with regards to preferences etc. This will further ensure that the routines are consistent and provide continuity of care for the individual service user. Feedback from relatives about the way care is delivered was for the majority, positive. Service users receive a range of additional, specialist support as and when required. The standard for Medication was not assessed fully at this inspection, but it was identified that gaps in the administration sheets need to be consistently explained rather than staff using their own interpretation or leaving it blank. Also, the home does not have a medication fridge or controlled drugs cabinet. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 16 Given that the service offers respite care it is required that these should be provided in the event that staff need to utilise the facilities. It is also recommended that the system for recording service users medication in the respite unit is held separately from the `long stay` unit. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 There is a clear complaints procedure for service users and relatives, thereby ensuring individuals views and concerns are listened to and acted upon. Arrangements for protecting service users through policy, staff training and awareness could not be confirmed. EVIDENCE: 68 Bescot Rd operates Lonsdale Midlands Ltd complaints procedure and records will be kept of any complaint or issues raised. No formal complaints had been received since the last inspection. The complaint procedure contains details of the Commission for Social Care Inspection, and the procedure is available to service users and representatives, in appropriate formats. The company’s complaints procedure details how to make a complaint, to whom and the timescales involved. The organisation has an Adult Protection policy, which has been referenced to the Department of Health guidance ‘No Secrets`. It was not possible to confirm if this policy has been brought to the attention of all staff, or the number of staff that have been trained in Adult Protection issues. The Registered Manager stated that the programme of training was to continue in 2006. Physical and verbal aggression by service users must be fully understood and dealt with appropriately by staff. Physical intervention is only to be used as a last resort by trained persons, in accordance with Department of Health guidance and is the minimum consistent with safety. It was not possible to confirm all staff have been trained in appropriate techniques. Records must be available to support this. The homes policy and practices regarding service users money/financial affairs was not examined in detail at this inspection. It was noted that a safe is provided for the safekeeping of monies and valuables. The Registered Manager 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 18 was also advised that a second witness signature is needed on all records of expenditure/income for service users monies, and that these should be regularly audited and balances checked. Staff should use their full names, rather than Christian names of financial records. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The premises and the standard of the environment within this home are good, providing service users with an pleasant and homely place to live. The premises are clean and effective infection control measures are in place. EVIDENCE: 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 20 68 Bescot was found to be comfortable, clean, airy and free from odours. The home offers access to local shops, towns, and public transport and is in keeping with the local community. The home offers limited external recreational space. Internally the bedrooms and communal areas were found to be well maintained and are decorated and furnished to a good standard. The premises offer a homely environment whilst ensuring safety and meeting National Minimum Standards. The premises are being maintained to a good standard by staff, on a day to day-to-day basis. The Registered Manager needs to develop a programme of routine maintenance and redecoration to address the future and ongoing renewal of the fabric/décor of the home This should identify priority areas and estimated timescales for planned refurbishment in addition to replacing furniture and fittings, and mechanisms for coping with more urgent maintenance issues. During a tour of the premises, a safety hazard was noticed. One of the windows on the first floor had been smashed and splintered glass was protruding from the frame. The Registered Manager was told that this needed to be repaired or made safe as a matter of urgency. Maintenance staff were called to the home before the end of this inspection. In addition, the door release system between floors had been disabled, which also required repair. At this inspection, the home was clean and hygienic. The parts of the home that were viewed, were home found to be free from odour. Laundry facilities are appropriate, sited in two separate areas, (one on each floor) designated for the purpose and do not intrude on residents routines. Washing machines have a specified programme to ensure certain laundry is washed at appropriate temperatures, has the appropriate sluicing facilities and walls, floors and the ceiling in the area are washable. A hand-washing facility is available although a paper towel dispenser is needed in both areas. Liquid soap, paper towels, disposable aprons and plastic gloves are available. Mops and buckets are colour coded but need to be clearly labelled for different areas of the home and when left to dry mops should be inverted. It is recommended that laundry procedures are displayed with a hand-washing poster. The storage of substances that may be hazardous to health (i.e cleaning products etc) is acceptable, although they are currently kept in a temporary location as the lock on the storage area door is broken. Training for staff in Infection Control measures was not analysed at this inspection, but the Registered Manager needs to ensure this is included in the staff training and development plan. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35 The home does not provide a staff team of whom 50 are qualified to at least NVQ level 2. Staffing levels are higher than average and staff shift patterns are flexible in order to deliver a needs led service. Recruitment practice lacks consistency and potentially places people who use the service at risk. Evidence of training and personal development for the staff is lacking and there are omissions in demonstrating a robust audit trail is in place. EVIDENCE: The home employs sixteen care staff. One has achieved an NVQ level 2 qualification. Five staff are enrolled or working towards the award. The Registered Manager needs to be more proactive in planning to meet targets set by the `Skills for Care` organisation and CSCI. The home generally provides in excess of the minimum staffing numbers as recommended by the Department of Health, but this is required due to the service offering specific packages of care, which include/require a higher ratio of staffing levels to meet the assessed needs of the service users. The ratios of staff to service user are dependant upon need but may include 1:1 or 2:1 at home or 3:1 for community inclusion. On the `long stay` unit staffing levels are maintained at 3 support staff per day. One service user is currently placed on the respite unit on a `long term` basis. Staffing levels within this area are therefore set at four support staff per 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 22 shift during the day. In addition to the support staff, there is a minimum of one qualified nurse on duty. For the majority of the working week the Registered Manager is supernumerary to the staffing levels. Night staffing levels are maintained at 3 support staff and a qualified nurse, which equates to 2 staff on each unit. The staffing levels above are the minimum the home must operate within. The staff duty rota was inspected and showed that the staffing levels fluctuate. The Registered Manager is advised of the need to monitor and adjust staffing levels to ensure the needs of service users are being met and where necessary contact the appropriate health professional to conduct a reassessment. A sample of staff files were viewed as part of this inspection. The home operates the company recruitment procedure, which includes taking two written references prior to appointment. Information contained in some staff files included application forms, (and statement of health/convictions) two written references, and proof of I.D. The Registered Manager was reminded to examine application forms thoroughly and explore the applicants employment history/reasons for leaving previous employment. In addition, the Registered Manager was advised that records of all staff interviews should be held and available. This should include who is on the interview panel, questions asked of candidates and the outcome. The sample of staff files examined indicated there was a lack of consistency in terms of the recruitment practice. The manager was advised in respect of action required for all new employees who are employed on the basis of a Protection of Vulnerable Adults `first` check. For example, ensure all other relevant checks/clearances are secured, (including 2 written references, one from the last employer), ensure that a record/evidence is kept at the home that an enhanced CRB check has been applied for, appoint a member of staff suitably qualified and experienced to supervise the employee, and conduct a documented risk assessment. There was evidence to confirm this practice had not been adhered to. This was brought to the attention of the Registered Manager. The Registered Manager has produced a training matrix and is attempting to demonstrate that each member of staff is provided with the relevant training. It is acknowledged that the Registered Manager continues to collect evidence of this in the form of certification on staff files. However, from examination of a sample of staff files and individual training records it was identified that certificated evidence for staff training was inconsistent. There is insufficient to confirm that staff have been provided with the relevant training, or induction and probationary/supervision meetings. The Registered Manager needs to produce a plan for the home detailing the staff training and development programme for 2006 and must include, for example, Basic Food Hygiene, National Vocational Qualifications, Infection Control, Adult Protection, Physical Intervention or similar. This must also clearly identify programmed dates of training, for completion during the coming year, and demonstrate that each member of staff is to be provided with a minimum of at least five days paid training. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 23 The induction system used is produced through the Black Country Partnership for Care organisation and is referenced to the `Skills for Care` induction standards. Staff will soon be able to access the Learning Disability Award Framework accredited training, (LDAF). Recently employed staff files provided limited documentation to support the above practice. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 The Registered Manager is experienced and qualified to run the home and meet its stated aims and objectives. There are elements of a Quality assurance system, but this needs to be formalised to ensure it is based on the outcomes for service users, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. The Registered Manager is seen to ensure as far as reasonably practicable the health, safety and welfare of service users and staff, but certificated evidence and methods of record keeping need to improve. EVIDENCE: The Registered Manager has appropriate qualifications and experience for the post, and undertakes periodic training and development to maintain her knowledge and skills, and evidence of this was available. She is a Registered Nurse (Learning Disability), holds an NVQ level 4/Registered Managers Award qualification, is a Non Violent Crisis Physical Intervention trainer and is a Learning Disability Awards Framework assessor. The Manager of the home 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 25 commenced in post during January 2005, and was registered under the Care Standards Act in March 2005. Lonsdale Midlands Ltd needs to consider formalising the quality assurance process for the care home. The Company holds the Investors in People Award but the home must evidence an effective system for Quality Assurance is in place based on the outcomes for service users, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. The company complaints procedure is available to all service users and their representatives, and is in suitable formats. Regular reviews of care plans and systems are held, and policies and procedures are being updated. In addition, various audits take place in the establishments, for example, estates audits. The Registered Manager is aware of the need to involve the service users and staff at Bescot Rd in the quality assurance process, but should continue to explore ways and methods of demonstrating the quality of service is appropriate, and include other stakeholders. The Registered Manager needs to produce an annual development plan for the home. This document should detail a system of planning, action and review for the establishment. It needs to reflect a self-monitoring tool which includes the Regulation 26 visits and the internal audits. The actual plan will incorporate other documents such as the homes aims and objectives, (subject to review), the maintenance and redecoration plan, the staff training and development plan, and details of outcomes from the quality assurance system, including any new or reviewed policies and procedures. Feedback from relatives about the service provided at Bescot Rd was generally favorable. Eight comment cards were returned to the inspector. All those who responded said they were welcomed to the home and all except one person said they were kept informed of important matters affecting their relative. Two relatives said they were unaware of how to make a complaint if the need arose, and that they felt there were not always sufficient staff on duty. Six out of seven people were satisfied with the overall standard of care being provided. Comments received include “My relative (name removed) goes to Bescot Rd for respite and I am more than satisfied with the standard of care he receives. He has settled well and is always happy on his return” “My relative (name removed) seems to be settling in quite well at Bescot and staff seem very good and forward thinking. The only problem I foresee is in the case of staff being changed too often” Two people commented on the difficulty they have in contacting the home by phone. It is said that the phone has on occasions, rang out for some time without being answered. Another relative commented on how some items of clothing have not been returned following her relatives stay at the home. A random sample of maintenance and service records was examined. There was some difficulty in examining certain records which the Registered Manager 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 26 stated had been mislaid. These were with regard to specific service contracts and records of staff being involved in fire safety practices. The Registered Manager was advised to review all of the required service contracts and testing certificates and collate the information available in order to address any identified shortfalls. 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score X 1 3 1 1 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 68 Bescot Road Score 2 X X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000062047.V257454.R01.S.doc Version 5.0 Page 28 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 YA3 Regulation 14 Requirement The registered person must demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home, and to demonstrate it offers care based on current good practice and reflects relevant and clinical guidance. 1. Ensure that service user plans cover all areas of assessed need and include all aspects of care: (emotional needs, healthcare, social needs, financial assistance, personal care etc.) 2. To produce care plans in a formats suitable for service users. 3. To ensure daily reports reflect goals identified in care plans. 4. To introduce effective evaluation, monitoring and reviews of service users plans which must be sufficiently detailed to reflect the changing needs of service users, and the objectives set.(Previous DS0000062047.V257454.R01.S.doc Timescale for action 30/06/06 2 YA6 5 30/06/06 68 Bescot Road Version 5.0 Page 29 requirement partly met) 3 YA7YA16YA18 12 1. The home must demonstrate how daily routines and house rules promote independence, individual choice and freedom of movement, are flexible and service users are enabled to exercise control and are subject to restrictions only as agreed in the individual Plan and Contract. 2. Individual working records should clearly set out residents preferred routines, likes/dislikes etc. To develop detailed individual risk assessments with regard to all service users’ activities within the home and in the community, i.e. personal hygiene/bathing, use of transport, day care, use of kitchen/laundry equipment, access to community resources etc. and ensure each one is regularly reviewed and updated (previous requirement partly met) The home must evidence that service users are enabled and supported to pursue interests/hobbies which are geared to the individuals choice and use the local facilities to undertake a variety of activities in addition to their main and regular routines (previous requirement partly met) • The management must evidence that service DS0000062047.V257454.R01.S.doc 30/06/06 4 YA9 13 31/03/06 5 YA13YA14 12,16 30/06/06 6 YA19 12 31/03/06 Page 30 68 Bescot Road Version 5.0 7 YA20 13 8 YA23 13 9 YA24YA30 23,13 users healthcare needs are being met, and procedures for routine screening and the monitoring of service users’ health with regard to potential complications, are adequate. • All service users must be enabled to receive annual health checks, such as attending `well person clinics` and records maintained (previous requirement partly met) • The home should have 28/02/06 a medication fridge and controlled drugs cabinet. • There should be no gaps in medication administration records 31/01/06 • The homes Adult Protection policy should be brought to the attention of all staff. • Records of expenditure/income for service users monies should be regularly audited and balances checked. Staff should use their full names, rather than Christian names of financial records. • The Registered Manager 31/03/06 needs to develop a programme of routine maintenance and redecoration to address the future and ongoing renewal of the fabric/décor of the home. • The door release system DS0000062047.V257454.R01.S.doc Version 5.0 Page 31 68 Bescot Road 10 YA34 18 schedule 2 11 YA35 18 12 YA39 24 between floors requires repair. (By 31/12/05) • Paper towel dispensers should be fitted in the laundry room. (By 31/01/06) • The Registered Manager 30/06/06 must ensure that staff application forms are examined thoroughly and explore the applicants employment history/reasons for leaving previous employment. A record of all staff interviews must be held and be available. • The Registered Manager must conduct a documented risk assessment for any new employees who are employed on the basis of a Protection of Vulnerable Adults `1st check`. The Registered Manager needs 28/02/06 to produce a plan for the home detailing the staff training and development programme for 2006 and must include, all training commensurate with their duties, for example, Basic Food Hygiene, National Vocational Qualifications, Infection Control, Adult Protection, Physical Intervention (or similar). This must also clearly identify programmed dates of training, for completion during the coming year, and demonstrate that each member of staff is to be provided with a minimum of at least five days paid training. • To produce an annual 30/06/06 development plan, which is based on a DS0000062047.V257454.R01.S.doc Version 5.0 Page 32 68 Bescot Road 13 YA41 17 14 YA42 12,13,23 systematic cycle of planning-action-review and reflects the aims and outcome for service users (by 31/3/06) • The service must adopt and evidence an effective system for Quality Assurance based on the outcomes for service users, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. • To explore ways in which the service users, staff and stakeholders can be included in the homes chosen quality assurance system. • All records required by 30/06/06 regulation for the protection of service users and the effective/efficient running of the business must be available for inspection. • Documentation must not include records of an inappropriate, subjective or discriminatory nature. Terminology used in reports must be regularly audited and reviewed against the practice within the home. (previous requirement partly met) 31/03/06 The Registered Manager must ensure as far as reasonably practicable the health, safety and welfare of service users and staff. a) The Registered Manager must review all of the required service DS0000062047.V257454.R01.S.doc Version 5.0 Page 33 68 Bescot Road contracts and testing certificates and collate the information available in order to address any identified shortfalls. b) Records of the core temperature of cooked foods being served, must be maintained. 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 Refer to Standard YA16 YA20 YA30 Good Practice Recommendations Personal mail for service users that is received at the home should be opened only with the prior agreement of the individual or their relative/representative. It is recommended that the system for recording service users medication in the respite unit is held separately from the `long stay` unit. • Laundry procedures and a hand-washing poster should be displayed in the laundry rooms. • Mops and buckets need to be clearly labelled for different areas of the home and when left to dry, mops should be inverted. The home should continue to work toward meeting Sector Skills Workforce targets of 50 of care staff having achieved an NVQ level 2 or above. 4 YA32 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 34 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 68 Bescot Road DS0000062047.V257454.R01.S.doc Version 5.0 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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