Inspection on 31/10/05 for 7 Wellington Street

This inspection was carried out on 31st October 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 no outstanding requirements from the previous inspection report, but made 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

7 Wellington Street 11/04/07

7 Wellington Street 18/05/05

7 Wellington Street 27/09/04

7 Wellington Street 21/04/04

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 7 Wellington Street West Bromwich West Midlands B71 1DR Lead Inspector Jayne Fisher Unannounced Inspection 31st October 2005 09:30 7 Wellington Street DS0000004774.V262648.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 7 Wellington Street DS0000004774.V262648.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. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 7 Wellington Street Address West Bromwich West Midlands B71 1DR 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 532 3556 NONE Pioneer Care Limited Ms Sandra Horsley Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 service user who may also have a physical disability Date of last inspection 18th May 2005 Brief Description of the Service: 7 Wellington Street is a semi-detached property which is rented from the Local Authority and is located in West Bromwich. The centre of town is within a two mile radius and there are local shops nearby. Public transport is good. The Home currently provides care for two persons with learning disabilities one of whom also has a physical disability. The Home is able to provide care for service users with complex needs and challenging behaviour. The accommodation includes: a dining area, lounge, kitchen, downstairs walk in shower and toilet, three bedrooms on the first floor, a bathroom and toilet, and sleeping in room. There is a Wessex style lift leading from the lounge area directly into one of the service users bedroom who has a physical disability. There is a ramp leading to the front door and back garden. There is off side parking on the road in front of the property. The garden to the rear is shared with No. 5 (which is also a care home owned by the same company). There is a patio and large lawned area which is secluded. Service users attend either Local Authority run day centres or have an in-house day care provision. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between the hours of 9.20 a.m. and 12.30 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: case tracking, formal interviews with the home leader, and two support staff who were on duty. There was also a tour of the premises. One resident was at home during the inspection. Open dialogue was not possible with residents therefore the inspector relied upon body language and observations of interactions between staff and residents. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of visits undertaken by the owner’s representative and an action plan submitted by the home following the last inspection. No. 7 Wellington Street provides intensive support for people who have a range complex needs. The majority of standards were examined at the last inspection and this report should therefore be read in conjunction with the previous inspection report to give an comprehensive overview. The findings of this inspection confirmed that the home is maintaining a high quality service. The inspector was made to feel very welcome and would like to thank the service user and staff for their assistance and co-operation during the visit. What the service does well: New residents are fully assessed prior to admission. This means that staff can ensure that they can meet the needs of residents. There are lots of opportunities for the new resident to meet existing residents in order for them to get acquainted and ensure compatibility with each other. The home offers a flexible service and residents can exercise choice in many aspects of their lives. Staff are patient in assisting residents to make decisions about their daily lives for example with regard to choosing clothes and accessories. Staff help residents with personal grooming which reflects their individual tastes and personalities. There is lots of emphasis in residents joining in the daily running of the home through independent living skills tasks. The home offers residents a varied and healthy diet. Residents are clearly able to exercise choice and assist in food shopping and preparation if they wish. There is a well trained staff group who are aware of residents’ specialist needs. Staff are enthusiastic and dedicated. One member of staff stated “I love my job, residents don’t want for anything’. There was lots of positive interaction observed; staff displayed a caring approach through out. There is lots of support given to enable residents to maintain their family links. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 6 There was a relaxed atmosphere on arrival. Staff make efforts to ensure that the environment is homely and comfortable for residents. There were fresh flowers and scented candles in the dining room. All areas of the home were clean and tidy through out. What has improved since the last inspection? What they could do better: Although there is a comprehensive assessment system in place for new residents, the manager must ensure that a letter of confirmation that the home can meet their needs is sent prior to admission. There is a very good care planning system in place with lots of information for staff to help them in providing support to residents. Residents also have a photographic/pictorial care plan which is an aid to help them understand their how their needs will be met. The home now needs to introduce different methods to assist residents to make their preferences and aspirations known, for example through ‘essential life style planning’. The home also needs to ensure that some elements of care plans are kept more up to date for example with regard to challenging behaviour. Risk assessments also need to be expanded in some areas and reviewed more regularly. The health care needs of residents are generally well met with only a couple of minor improvements required. Medication practice also needs slight attention. As identified previously, although there are community based activities, there needs to be more staff on duty on a more regular basis so that all residents can make choices as to whether they want to go out together, or on their own with the support of staff. Activity programmes now need to be updated as they were first established in 2003 and now need to be reviewed. Improvements are also needed in making sure the duty rota is up to date and that there is more regular formal supervision of staff. Health and safety practice is good with a couple of exceptions. The Commission for Social Care Inspection is still not receiving monthly reports from the owner’s representative who does visit the home on a regular basis. Copies of reports were also not available at the home. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 7 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. 7 Wellington Street DS0000004774.V262648.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 7 Wellington Street DS0000004774.V262648.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): 2 New residents are admitted only on the basis of a full assessment thereby ensuring that their individual aspirations and needs can be met. EVIDENCE: Since the last inspection a new resident has been admitted to the home, which is now fully occupied. It was very pleasing to see the care taken by staff to ensure that this was a smooth process with plenty of opportunities offered for the new resident to visit the home on introductory visits. There were detailed records completed during these visits, on a proforma specially designed for this purpose. In addition staff had obtained relevant documents from the placing officer which included a care plan and assessment. Staff have also completed their own assessment of need tool entitled ‘my way’. This is a comprehensive document which covers a range of subjects. There is only one minor issue in that the manager failed to write to the prospective resident confirming that they could meet assessed needs as required by the Care Homes Regulations 2001, 14(1)(d). 7 Wellington Street DS0000004774.V262648.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): 6 and 9 The home has a good care planning system so that service users know their assessed needs and personal goals are reflected in their individual plan. Only slight expansion is needed to ensure that all care plans are updated more frequently as and when needs change. Similarly risk assessments are also holistic but would benefit from more regular review and slight expansion so that staff have suitable guidelines for supporting residents to take risks. EVIDENCE: All care plans were examined as part of case tracking. At the last inspection care plans were required to be updated specifically with regard to challenging behaviour. One resident’s care plan has been updated but further details needed to be added particularly with regard to sexualised behaviours. Part of the care plan still refers to ‘as and when required’ (PRN) medication which the resident is no longer receiving. Another resident’s care plan also needs updating since it was originally implemented in October 2003 and April 2004. The care plan refers to ‘medication’ but does not contain specific details of the PRN medication which the resident receives in the form of Lorazepam. Staff also require guidelines in the care plan as to when to complete incident report forms. These are now being completed on a more frequent basis but upon 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 11 discussion with staff it was agreed that more clarification regarding the completing of forms would be beneficial. As identified at the last inspection, although residents have care plans which have creatively been reproduced in pictorial and photographic formats, this system now requires further expansion to include an essential life style planning which will enhance the system further due to service users’ complex communication needs. This has not yet been introduced. There is a good risk management process but some risk assessments did not appear to have been reviewed since implementation in April 2004 and 2003. Staff also agreed that one resident’s risk assessment regarding challenging behaviour required review as there was a ‘medium’ risk identified with a low probability rating which had now increased. There were no risks considered with regard to travel on transport and this needs to be assessed. At the last inspection it was highlighted that risk assessments needed updating with regard to wheelchairs mainly due to new risks which had been identified by the Medicines and Healthcare Products Regulatory Agency earlier in the year. Information was supplied to the home on the day of the inspection. These still require updating. 7 Wellington Street DS0000004774.V262648.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): 13, 15 and 17 Links with the community are good however more opportunities could be offered for service users to go out as individuals rather than in a group, which would further enrich their lives. Staff fully support residents to keep links with their families thereby ensuring important relationships are maintained. Meals are good offering residents both choice and variety. EVIDENCE: As identified at the last inspection more opportunities need to be offered to all residents to undertake communities on an individual basis. The home leader states that a request has been made to the Local Authority commissioning unit to seek more funding to over come this shortfall. A response has yet to be received. It was pleasing to see that the new resident goes out on a regularly on an individual basis as funding has been secured to provide an in-house day care provision which is geared towards a tailor made service which is commendable. However, although on occasions a third member of staff is made available in order for community outings to take place, as before more opportunities should be available for residents to go out on their own, as opposed to in a group. For example, during October 2005 examination of daily diaries demonstrated that apart from attending a their day centre, one resident 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 13 had only been out on one community based activity which was with another resident. Interviews with staff and examination of daily records confirmed that all residents are fully supported to maintain links with their families. Some relatives visit the home to see their family member. It was reassuring to see the efforts made by staff. For example, they had taken one service user to see their family member who was in hospital. Staff said they were maintaining telephone contact with this relative who is too poorly to visit the home at present. This is commendable. The Home does not have a formal menu plan as service users are able to choose for themselves what they would like to eat on a daily basis which is an excellent initiative. Service users’ food options are fully recorded and confirm that they are able to exercise individual choice. Interviews with staff were positive in how they assisted residents to make their choices using a pictorial menu and using objects of reference. Staff rely on their knowledge of residents’ individual likes and dislikes with regard to planning the weekly food shopping. On examination residents’ pictorial care plans confirmed what they like or don’t like to eat. This also demonstrated that staff were clearly familiar with their preferences as confirmed during interviews. It was pleasing to hear plans of how the new service user is going to participate in shopping trips, an activity which the inspector is informed is not appropriate for the two other residents. Examination of food options chosen by residents confirm that the food provided is nutritional, well balanced and varied. On inspection fridges and freezers were well stocked with good quality products. There was a good supply of fresh fruit. (See comments in standard 19 with regard to nutritional screening). 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 The health needs of service users are well met and close observation helps identify any potential complications at an early stage, ensuring service users’ receive the treatment they require. Slight improvements are needed with regard to more active monitoring in certain aspects such as routine health care appointments so that residents receive these on a more regular basis. There are good procedures relating to the control and administration of medication, although further improvement is necessary in some areas to ensure all practices comply with professional guidance. EVIDENCE: Case tracking confirms that good standards are being maintained with regard to ensuring residents’ health care needs are met. There are excellent recording methods to identify any potential complications from testicular, breast and cervical cancer, bowel and other health related issues. The inspector was informed that a new care plan with regard to cervical screening had recently been introduced with the support of the community learning disability team. There are excellent procedures in place with regard to pressure area care. There are also detailed records maintained by staff with regard to the outcome of any appointments with medical practitioners, as is good practice. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 15 The home carefully monitors eating and encourages service users to follow a healthy eating plan. As a result one resident has recently lost some weight. The home leader states that they have made a referral to the community dietician to seek help in determining the correct goal weight for this resident taking into account their body mass index. Nutritional screening and assessment tools have been completed, but these now require review as they were established in October 2003 (as identified at the last inspection). In the past the home has experienced difficulties in weighing service users and have tried to employ different strategies. For example, one service user is weighed on attendance at regular hospital appointments. Further information was supplied by the inspector with regard to alternative measures such as the ‘malnutrition universal screening tool’. This has not yet been adopted by the home. Residents have yet to receive a hearing test as previously required. There is a health care appointment summary sheet to assist staff in monitoring appointments. However, although the record detailed that an appointment was due for one resident to have a dental check up in May or June 2005, on case tracking with staff this was not carried out. The last dental check for this resident was in November 2004. Staff must ensure that this monitoring record is regularly reviewed and action taken to pursue any outstanding appointments (with records maintained). A full evaluation of the control and administration of medication practice operated by staff took place and demonstrated that there are very good procedures in place, only a small number of improvements were identified. Medication is held secure, there were no gaps on medication administration record (MAR) sheets, only prescribed medication is administered and there are good records relating to the receipt and disposal of medication. There is a ‘medication agreement’ form in residents’ case files as well as an up to date medication profile. It was pleasing to see that upon admission the placing officer had confirmed in writing the current medication regime of the new resident. As previously identified, the medication policy requires slight expansion. The pharmacist is not visiting on a quarterly basis as per the contract with the health authority to provide this level of service. Staff still need to ensure that when writing hand written instructions on MAR sheets that there are two staff initials to confirm instructions regarding administration are correct. Any other items discussed during this inspection of this standard are contained within the Requirements section of this report. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed at the last inspection. EVIDENCE: There are a couple of outstanding items relating to these standards. The home leader states that staff have received training in vulnerable adult abuse (which was confirmed during interview with a support worker). Training certificates are still awaited as confirmation. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 17 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): 30 The premises are kept clean and hygienic through out and residents benefit from systems in place to control the spread of infection. EVIDENCE: The premises were clean and tidy through out with no offensive odours. There is a domestic washing machine located in the kitchen which is suitable for the needs of service users and type of service provided at No. 7 Wellington Street. During interviews staff confirmed that they do not undertake washing of laundry whilst food preparation is underway. Staff confirmed that there is no manual sluicing of soiled items. It is recommended however that a fresh supply of water soluble bags are obtained for emergencies, such as the need to wash infected linen. There is a lockable clinical waste bin and staff have received training in infection control. There were good supplies of paper towels and liquid soap available in the kitchen. Personal protective clothing was also available in the ground floor communal bathroom. It was pleasing to see regular testing of the water temperatures which is a safety measure in respect of Legionella. There were no communal items in bathrooms. There was a plastic jug however in the first floor bathroom. Staff stated that this was solely used for 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 18 the rinsing of one resident’s hair whilst in the bath. was scratched and worn and needs replacement. The jug although clean 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 19 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): 34 There are robust procedures relating to the recruitment and selection of staff; only one area needs improvement in order to offer more safeguards to residents. EVIDENCE: One new member of staff has been appointed since the last inspection. Examination of the personnel file revealed that appropriate pre-employment checks had been obtained prior to appointment. The member of staff commenced employment on 15 August 2005 and had been appointed without awaiting the return of a satisfactory criminal record bureau (CRB) disclosure and protection of vulnerable adult (POVA) check. However, in extenuating circumstances the Care Homes Regulations 2001, Regulation 19 allow staff to be appointed whilst awaiting the return of a satisfactory CRB disclosure on certain provisos. It was reassuring to see that the home had complied with these Regulations and a POVAFirst check had been undertaken and received prior to the staff member starting employment. However, management had failed to inform the Commission for Social Care Inspection (CSCI) that they were going to appoint a new member of staff without a CRB disclosure and there was no written risk assessment in place with regard to control measures in place to minimize risks to residents whilst awaiting the return of the CRB. This risk assessment should have been undertaken and forwarded to the CSCI. As discussed with the home leader, the POVA guidelines require that where staff are appointed on a POVAFirst that the employer actively pursues the 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 20 progress of the CRB disclosure with the criminal record bureau in order to ensure that the applicant is not purposely delaying the processing of the check (and to maintain records of this contact). This has not been done and steps must be taken to pursue this check as a matter of priority. The duty rota was examined as part of case tracking. There has been no regression in staffing levels, however, the rota does not contain the hours worked by the registered manager (who usually spends one day a week at the home as she is also responsible for a number of other establishments). Management need to improve the frequency of staff supervision sessions. For example, one member of staff had not received a supervision session since March 2005, and another member of staff had not received supervision since April 2005. Disappointingly the new member of staff had also not received a formal supervision session since beginning employment in August 2005. Any other items discussed during this inspection are included in the Requirements section of this report. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 21 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): 42 Management ensure so far as is reasonably practicable the health, safety and welfare of residents and staff; although slight improvements would assist this process even further. EVIDENCE: Health and safety was assessed at the last inspection. It was pleasing to see that progress has been made with regard to items which were identified as needing action. For example, fire drill records now contain the initials of staff participating, which helps ensure that all staff undertake a drill at least six monthly. Staff have now received fire safety awareness training which was confirmed on examination of training certificates and interviews with staff. Health and safety training has also taken place according to the home leader but this will remain partially addressed until training certificates are obtained as confirmation. On the whole there is excellent procedures in place to ensure staff have received up to date mandatory training. There is regular weekly testing of smoke alarms which is fully recorded. There are a couple of items which still require attention. For example, observational 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 22 checks undertaken with regard to bedrails and wheelchairs and to ensure that these are fully recorded. There were some substances hazardous to health (COSHH) found unsecured in the communal bathroom and care must be taken by staff to ensure that these are kept locked at all times. There was very good practice relating to food hygiene with regular cooked food fridge and freezer temperatures checks and good records maintained. There are a couple of items which need addressing in ensuring food is labelled with the date of opening and frozen food labelled with the date of freezing. Any other items discussed during this inspection are contained within the Requirements section of this report. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 2 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7 Wellington Street Score X 2 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000004774.V262648.R01.S.doc Version 5.0 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1)(d) Timescale for action The registered person must 01/12/05 confirm in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting their individual needs in respect of health and welfare. To ensure behavioural care plans 01/04/06 are kept up to date and identify any new strategies for deescalation. (Previous timescale of 1/10/05 is not met). To further progress person centred planning with essential life style planning, life story books etc. (Previous timescale of 1/10/05 is not met). To review and expand risk 01/02/06 assessments for wheelchair users identifying risk associated with using posture belts and manufacturers specifications with regard to maintenance checks and servicing. (Previous timescale of 1/7/05 is not met). To carry out individual written risk assessments with regard to all aspects of care including: 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 25 Requirement 2. YA6 15 3. YA9 13(4)(c) travel on minibus and/or public transport. To ensure that all risk assessments are reviewed at least annually or sooner depending upon risk rating. Staff must date and sign risk assessment to demonstrate it has been reviewed if no changes are made. To review and update 01/02/06 indivdiualized activity programmes to identify and reflect service users preferences and needs. (Previous timescale of 1/10/05 is not met). To provide more opportunities 01/02/06 for service users to undertake community based activities on an individual basis. To undertake a review of staffing levels to ensure they are sufficient to undertake these tasks. (Previous timescale of 1/8/05 is not met). To make the following 01/01/06 improvements with regard to healthcare monitoring and recording: 1) To ensure that service users receive regular eye tests, dental checks and hearing tests. (Previous timescale of 1/7/04 is partly met). 2) To introduce a formal procedure with regard to observational weight checks. (Previous timescale of 1/7/04 is partly met). 3) To ensure care plans contain up to date details with regard to continence management. (Previous timescale of 1/7/04 is partly met). 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 26 4. YA12 12(1)(a) 5. YA13 16(2)(m) 6. YA19 12(1)(a) 4) To review and update nutritional screening and assessment tools. (Previous timescale of 1/10/05 is not met). 7. YA20 13(2) To make the following 01/03/06 improvements to the control and administration of medication: 1) To review and expand medication policy using guidelines issued by the British Pharmaceutical Society, June 2003. (Previous timescale of 1/4/04 is partly met). 2) To ensure copies of reports following pharmacists visits are obtained. (Previous timescale of 1/4/04 is not met). 3) To continue to progress plans for ensuring all staff receive accredited training in the safe handling of medication. (Previous timescale of 1/4/04 is partly met). 4) To consult with pharmacist to request that regular as and when required (PRN) treatment is included on computerized medication administration record (MAR) sheets. (Previous timescale of 1/10/05 is not met). 5) To ensure that any handwritten instructions on MAR sheets are signed and witnessed by two members of staff to confirm accuracy. (Previous timescale of 1/10/05 is not met). 6) To ensure that staff check prescriptions and sign exemptions before being dispensed by the pharmacist. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 27 8. YA23 13(6) 7) To request that the pharmacist visits on a quarterly basis as per contractual agreements with the health authority. To review and update the 01/04/06 vulnerable adult abuse procedure to ensure that it contains details of new Protection of Vulnerable Adults (POVA) scheme. (Previous timescale of 1/9/05 is not met). To continue to progress training for all staff in vulnerable adult abuse. (Previous timescale of 1/9/05 is partly met). 9. YA24 23(2)(b) To securely fix wardrobes to bedroom walls. (Previous timescale of 1/1/05 is not met). To ensure that bedrails are checked on a regular basis to ensure that they are securely fixed with records maintained. (Previous timescale of 1/1/05 is partly met). 01/01/06 10. YA30 13(3) 11. YA31 18(1)(a) To replace stained carpet on the landing. (Previous timescale of 1/9/05 is not met). To dispose of worn plastic jug 01/12/06 which is used for rinsing of one service user’s hair and to ensure that the replacement is clearly labelled with name of resident. To review support workers job 01/04/06 descriptions to ensure that these reflect the roles and responsibilities of care home staff as opposed to domicillary support workers. Reference must be made to the code of conduct set by the General Social Care Council. (Previous timescale of 1/10/05 is not met). DS0000004774.V262648.R01.S.doc Version 5.0 Page 28 7 Wellington Street 12. YA32 18(1)(c) To ensure that 50 of the care staff team are qualified to NVQ 11 or above by 2005. (Previous timescale of 01/10/05 is not met). To pursue plans to ensure that all staff receive training in managing challenging behaviour including breakaway techniques. (Previous timescale of 1/10/05 is partly met). To cease using correctional fluid on the duty rota. 01/01/06 13. YA33 17(2) 01/12/05 14. YA34 13(6) 19 To ensure that the hours worked by the Registered Manager are recorded on the duty rota. To undertake a written risk 14/11/05 assessment for any new staff who are employed pending the return of a satisfactory criminal record bureau disclosure check. This must identify control measures to safeguard service users from abuse and comply with the Care Homes Regulations 19(11) and 19(12). This must be discussed with the Commission for Social Care Inspection (CSCI) prior to appointment and a copy forwarded to CSCI. To actively pursue the return of a criminal record bureau disclosure check for a member of staff who commenced employment on 15 August 2005. Records must be maintained to evidence that contact has been made with the criminal record bureau (or the Registered Body). To ensure that all staff receive 01/02/06 regular recorded supervision (at least six times per annum). (Previous timescale of 1/1/05 is not met). DS0000004774.V262648.R01.S.doc Version 5.0 Page 29 15. YA36 18(2) 7 Wellington Street 16. YA37 18(1)(a) 17. YA39 24 18. YA41 17(2) 19. YA42 23(2)(e) 20. YA42 13(4)(c) To ensure that the Registered Manager is qualified to NVQ 1V in care by 2005. (Previous timescale of 31/12/05 has not yet elapsed). To provide evidence that the quality assurance system includes feedback from stakeholders including doctors, district nurses and other professionals, as well as families and relatives. (Previous timescale of 1/1/05 is partly met). To obtain and hold information and documents in respect of persons carrying on, managing or working at a care home as listed in Schedule 4 of the Care Home Regulations 2001. (Previous timescale of 1/4/04 is partly met). To ensure that wheelchair maintenance checks undertaken by the home are fully recorded. (Previous timescale of 1/8/05 is not met). To make the following improvements to food hygiene: 1) To ensure that all food frozen by the home is labelled with the date of freezing and use by date. 2) To ensure all food stuffs with a which have to be consumed within a specific timescale upon opening, for example mayonnaise, are clearly labelled with the date of opening. 3) To ensure that upon opening all dried foods such as cereals are stored in pest proof containers. To ensure that substances hazardous to health (COSHH) are securely stored at all times. DS0000004774.V262648.R01.S.doc 31/12/05 01/04/06 01/12/05 01/01/06 01/12/05 21. YA42 13(4)(c) 01/11/05 7 Wellington Street Version 5.0 Page 30 22. YA42 18(1)(a) To ensure all staff receive training in: health and safety awareness. (Previous timescale of 1/10/05 is partly met). 01/01/06 23. YA43 17(2) 26(4) To ensure that the business plan is individualized to reflect the service provided by the home as well as being a corporate document. (Previous timescale of 01/09/05 is not met). To ensure that copies of the monthly reports from visits undertaken by the Owners representative are available on the premises and a copy forwarded to the Commission for Social Care Inspection. To ensure that the reports contains information in sufficient detail as requried by the Care Homes Regulations. (Previous timescale of 1/9/05 is not met). 01/01/06 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 YA6 YA23 YA30 Good Practice Recommendations To consider introducing antecedent behavioural consequence (ABC) charts. To consult with insurers to seek confirmation as to the total sum of service users monies which may be held on the premises at any one time. To obtain a further supply of water soluble bags (dissolvo sacs) as a precaution, for the washing of any infected laundry. 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 7 Wellington Street DS0000004774.V262648.R01.S.doc Version 5.0 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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