Inspection on 19/01/09 for 76 Holland Street

This inspection was carried out on 19th January 2009.

CSCI found this care home to be providing an Poor service.

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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

76 Holland Street 13/01/10

76 Holland Street 15/01/08

76 Holland Street 07/06/07

76 Holland Street 31/10/06

76 Holland Street 24/04/06

76 Holland Street 08/11/05

76 Holland Street 06/05/05

76 Holland Street 14/02/05

76 Holland Street 27/07/04

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 16/02/2010.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 76 Holland Street Holland Street, 76 Sutton Coldfield West Midlands B72 1RR     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Monica Heaselgrave     Date: 0 9 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 48 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 48 Information about the care home Name of care home: Address: 76 Holland Street Holland Street, 76 Sutton Coldfield West Midlands B72 1RR 01213542789 01213550832 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Social Care and Health Name of registered manager (if applicable) Gillian Charmaine Gayle Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: The maximum number of service users who can be accommodated is: 22 The registered person may provide the following category of service only: Care Home Only (Code PC); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) 22, Physical disability (PD) 22 Date of last inspection Brief description of the care home The home is a large two-storey building of modern design and appearance. It is set within its own grounds occupying a corner position. The home is located in a residential road in Sutton Coldfield with good access to shops and transport links. The gardens at the rear of the home are spacious and secluded. There is parking facilities to the front and rear of the building. The home currently provides accommodation to fifteen adults who have a learning Care Homes for Adults (18-65 years) Page 4 of 48 care home 22 Over 65 0 0 22 22 Brief description of the care home disability. Some people have additional physical disabilities and behaviour that may challenge. Each person living there has a single bedroom. The home is arranged over four different living areas. On the first floor people are supported to live more independently and are involved in meal planning and household tasks. This part of the home is known as minimal care. The physical standards of the home do not meet the needs of people with additional physical disabilities. The manager said that CSCI inspection reports are on display on the notice board in the hallway and the outcome of inspections are shared with people living in the Home and staff during meetings. The amount people pay to live at Holland Street is worked out for the individual with their social worker. The items not covered by the fee include clothing and toiletries. People pay for their own activities. The information included in this report applied at the time of inspection and the reader may want to obtain more up to date information from the care service. Care Homes for Adults (18-65 years) Page 5 of 48 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The focus of inspections undertaken by the Commission for Social Care inspection is based upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements and minimum standards of practice whilst focusing on aspects of service provision that needs further development. The Home is re providing its service which means it is due to close. The main focus for the home is to ensure people are receiving the right care and to support them during the re provision process. The inspection took place over four days. The first day was unannounced and the Care Homes for Adults (18-65 years) Page 6 of 48 Home did not know we were coming. During this period we met four families. We sent out surveys to relatives and three of these were returned. Over fifty percent of relatives were spoken with or responded to our survey. We spoke with care staff and managers who work in the Home and people who support the Home. This included an advocate and social worker. Four people were identified for close examination this included reading all the relevant information about them. This is part of a process known as case tracking which helps us understand the experiences of people who use the service. We met people living at the Home and spent time observing support and interactions from staff. The care records and health care records of people were looked at. We looked at their medication and their bedrooms. Health and safety records and staffing records were also assessed. All information looked at was used to determine whether peoples varied needs are being effectively met. We looked at information about incidents and accidents the Home had told us about. Information was also gathered from a serious incident that had occurred in the home in December 2008 which we had not been told about. The manager completed an AQAA. This is an annual quality assurance assessment which tells CSCI about how well the Home is performing and achieving outcomes for the people who live in the Home. Information from the AQAA was used to help inform the inspection process. The inspection was concluded on 9th February. Holland Street was assessed as a poor service. Holland Street has deteriorated in how it delivers key aspects of care. This could mean people are not safe. As a result of concerns identified on 9th February the provider was asked to take immediate action. The immediate concerns related to care planning and health care monitoring. There were also serious concerns about fire safety and the risk of scolding from hot water. It was found at the random inspection on 3rd march that the immediate improvements we asked for had been made. Additional requirements and improvements have been made at this inspection which need to be addressed. What the care home does well: What has improved since the last inspection? What they could do better: The Home must get better at maintaining the improvements we ask it to make. This is to ensure that people are cared for in a safe way and that the home is well run for the people living there. Most of the improvements are things we asked them to do before. It is important Holland Street operates within the law and provides care that meets the needs of people. Care Homes for Adults (18-65 years) Page 8 of 48 There must be an up to date care plan in place for all of the people living in the Home so that staff know how to support people. These must include details of health needs so they receive the care and support they need. This includes night time routines so that staff knows what support to provide and what checks to carry out. It should be clear how each person is supported to make choices and decisions about all aspects of their daily lives so that their care is based on what they want. People should be offered a choice of activities to do in house and in the local community and these should be in their care plan. The support people need at mealtimes should be written in their care plan so that all staff knows the best way to support the person. Care plans must be followed so that people get the support they need to keep them well and safe. Staff must monitor those people who have been identified as having health care needs. This includes weight monitoring and fingernail care. It is not clear that people have received the right help and support to meet these health care needs. Health Action plans needs further development so that they are an up to date record of the health care needs of people. Staff must follow the medication procedure so that medication is put away safely and people are not at risk of eating it. Risk assessments must be in place for all the activities people engage in. They must be signed and dated so staff knows they are the current one to follow. They should state clearly what the risk is and how it will be managed so people are not at risk of harm. There are serious doubts about the ability of the home to safeguard people and follow the procedures that are in place to protect them. All staff must know what to do should an incident occur. They must be clear how to report incidents and who to report them to. All staff should have up to date training in adult protection so they know how to protect people. An audit of the equipment which is provided to support people must be undertaken to ensure it is safe for use. Staff must have fire safety training so that they know how to support people safely in the event of a fire. All staff must follow the procedures for fire safety testing so that they can be sure people live in a safe house. Water temperatures must be checked and repairs made so that people are not at risk of scolds. Quality assurance systems should show how the Home is making improvements. Care Homes for Adults (18-65 years) Page 9 of 48 Staffing levels must be maintained so that the needs and welfare of the people using the service can be met. All staff should interact with all the people living there to ensure their self esteem and well being. Training for staff was not evident in some areas. There should be an up to date plan to show what training has been done and what is planned. Staff training in epilepsy and manual handling is needed so that they can support people safely. The management arrangements must be more robust to ensure a better level of accountability in the running of the Home. There must be a management team with enough seniors to make sure the Home is run smoothly. Managers must monitor the care practice more closely and ensure health and safety and other procedures are followed and do not put people at risk. The delegation of management tasks must be clearer so that important checks can be picked up quickly and managed appropriately. The owner has made the immediate improvements we asked for to keep people safe. They must now ensure that improvements are sustained to ensure that the home is well run for the people living there. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 10 of 48 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 48 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Holland Street has developed information to help people understand the service it provides. Evidence: The provider has informed the Commission that it will re provide the service. The people who live at holland Street have done so for many years and assessment information is now out of date. These standards could not be fully assessed as it is not intended that new admissions to the home will be made. One new person was staying at the home. The team manager stated that this was a short term arrangement and that the assessment of needs identified the home could meet this persons immediate needs on a short term basis. The plan of care for this person is being managed seperately from the re provision programme. The person centred planning team has been working with people with a view to identifying their future accommodation needs. Several families spoken with confirmed that this process was underway but as yet no timescales or future locations had been made known to them. People living at Holland Street have information about what the home provides. This remains unchanged since Care Homes for Adults (18-65 years) Page 12 of 48 Evidence: the last inspection visit. Care Homes for Adults (18-65 years) Page 13 of 48 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans and risk assessments do not always reflect the support individuals need to do the things they wish to do and to keep them safe. Some people are involved in decision making such as day to day living and social activities. Other people need further support to identify their choices and to ensure their decisions are reflected in their care plan. Evidence: We expect to see a care plan that is personal to the individual and clearly shows the best way for staff to support individuals in all aspects of their care. Four people were identified for close examination this included reading their care plans risk assessments daily records and other relevant information. Each person had an Individual Service Statement ISS. This is a break down of the key needs in the care plan so that care staff has a plan to support each person. It was positive to see the individual was involved in the review of care plans. Where people were able to they had signed their care plan to say they agreed to it or their response was recorded to indicate if they Care Homes for Adults (18-65 years) Page 14 of 48 Evidence: were happy or not with the plan. Some plans had a profile of the daily routine which was helpful in identifying how people liked things done and at what time. This made their plan more personal to them. One family stated that the care plan was a fair representation of the individuals needs and that they had contributed to the plan to ensure needs were met. Three other ISS were looked at and some gaps in information were noted. For instance one had no date so this does not help to know if it is the current plan. Two ISS and care plans lacked information such as personal care routines and preferences. This is particularly important where people cannot easily verbalise their preferences or staff is not familiar with individuals needs. Some inconsistencies were seen between what staff said people needed support with and what was recorded. The risk assessments to support the ISS were sometimes vague or not evident at all. Discussion with staff demonstrated that they had significant information about the risks to people and how to provide that care but when asked if a risk assessment was in place they were not sure. If staff are not aware of the risk assessment then the safety of people is compromised and the ability of staff to be consistent is hindered. The risk assessment should contain specific guidance as to what staff needs to do to support people safely. One risk assessment told staff to be aware of the persons whereabouts. This related to going out independently. There was no further detail as to what staff should be doing to support the person. It was not recorded whether he had appropriate identification on him or contact numbers or what to do if the person did not return. The risk assessment had no signature of the person who had devised it and no evidence of it being reviewed to ensure it was still appropriate for the persons needs. Another risk assessment had no date and was not signed by the person who had devised it. The risk was not clearly stated. It indicated that staff should discuss management with the person. There was no information as to what to discuss or how this was to be monitored and by whom. A risk assessment for falls was inadequate. It did not specify the control measures to minimise the risk and there was no action plan in place to guide staff in the steps to take to minimise the risk. The quality of these risk assessments is poor. They fail to identify how risks are managed and minimised. Risk assessments need further development to ensure people are safe in their activities. All risk assessments should be dated and signed so that there is some accountability for the standard and format. Care Homes for Adults (18-65 years) Page 15 of 48 Evidence: A risk assessment and protocol was recently drawn up for one person following a safeguarding investigation. Staff have identified other people who access the community independently or in twos. Risks assessments and protocols need to be developed for these people to ensure their safety. Moving and handling assessments should identify the control measures in place to include details about the equipment to be used. The sling size and staff training and safety checks of equipment. The assessments must be developed so that people are supported safely. Staff training records indicate that staff is not up to date with moving and handling training and this could mean they do not support people safely. There is no record of staff being observed using equipment to ensure they know how to use it safely. One family expressed concerns about night support needs. Complaints had been made about supervision during the night. This individual had some falls resulting in hospital treatment. Risk assessments for the support people require during the night from waking night staff require review. They must include specific information about the individual support needed. For instance whether they are checked discreetly from the doorway or whether staff enters the room. There should be information to guide staff in what they are looking for and what level of supervision is needed when a person is not sleeping but is active. Staff must identify the risks this may pose. This must be documented which will ensure people receive the right support and supervision from night staff. An audit of risk assessments and manual handling assessments is needed to ensure those areas where people need support is clearly identified and that the control measures are specific to that person. It is not clear who writes risk assessments as some are not signed or dated. Staff would benefit with training in this area to ensure risk assessments are of a good quality and a consistent format adopted. A review of the recording system is needed. Currently staff uses a number code which relates to tasks in the ISS or risk assessments to describe which task they have supported the person with. This does not provide a good audit trail of what has happened for that person or how they responded to care. Care plans could be further developed so they show clearly what people like to do socially as well as identifying where they need support. Those looked at showed that the outcomes are variable. Some people make choices and these are reflected in their plan whilst others had little information as to their routines or interests. Information taken from the AQAA tells us that the manager has recognised that further work is needed in this area. She has stated that a more pro-active response is needed Care Homes for Adults (18-65 years) Page 16 of 48 Evidence: rather than a re-active response. Holland Street has many agency staff and some new Lifeways staff who rely on accurate records to follow when meeting the needs of people. It is important to ensure consistency that care plans are detailed. Care Homes for Adults (18-65 years) Page 17 of 48 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all of the people are supported to take part in valued activities. Further development of choices would ensure people are able to do the things that they like that are important to them. There is active support from families which ensures people have increased activities which they enjoy. People are offered a varied diet but the support they receive at mealtimes and to sustain a healthy diet varies. Evidence: Not everyone living at Holland Street has the opportunities to do things that they value on a frequent and regular basis. Most people attend day centres on weekdays. Their links with these places are well established and the familiarity of these routines is very important to them. Some people do not attend day centres but their opportunities during the day are variable. On two of the four visits to Holland Street observations of activities showed that sometimes people were left to occupy themselves. One person Care Homes for Adults (18-65 years) Page 18 of 48 Evidence: was wandering around the dining area holding the wet floor warning cone. The staff member sat in the lounge seemingly watching the T.V. On another occasion two people sat in their wheelchairs whilst staff wrote their daily records. The T.V was on and the level of interaction between staff and people living there was minimal. One person sat for a length of time in the small lounge with a staff member sat across the room. There was no verbal interaction at all. In comparison on two visits the level of activity was good there was additional staff from Lifeways and from the day centre. People were supported to do arts and crafts during the morning and some of the people observed to be solitary on the previous visits were observed to engage in this positively. A trip to the cinema and a meal out was also planned for the following day. On the day of the cinema visit one person said how pleased he was to be going to the cinema. Staff interacted well and asked the people what film they would like to watch and what they would like to have for their lunch out. People were excited and clearly looking forward to their trip out. Some people do not attend a day centre. Staff said they have opportunities to go out for lunch or a walk or a planned trip for shopping or the hairdressers. Staff said that sometimes this was not possible because of staffing levels which over the last few months had been difficult. They also had to rely on transport from the day centre and the availability of a driver. Overall staff said that they felt social trips out had increased. Some people are consulted regarding their choice of daily activity but this process could be improved by extending it to those people who cannot easily communicate their interests and choices so that they have a fullfilling lifestyle. Discussion with parents and comments from surveys indicated that the frequency of social events and levels of interaction and stimulation has been a concern. Parents felt that there is little organisation and that the level of interaction was dependant on the staff members on duty. Some parents stated that some of the staff including agency staff were very good and understood the individual needs of people and engaged them well. Other relatives felt staff provided basic physical care but did not engage the people living at Holland Street. Comments had been received indicating some staff were observed sitting watching the T.V. or writing reports with no activities taking place. This was observed during this inspection. Concern was expressed about a weekly social club which had not been attended for a number of weeks. Parents said this had been due to a problem with transport which in their view the managers at Holland Street had not taken steps to resolve. In the interim several people who enjoy this activity had missed out. Daily records were looked at and showed that some of the people had celebrated a range of celebrations such as Christmas and birthday parties. A barbeque had been Care Homes for Adults (18-65 years) Page 19 of 48 Evidence: organised and enjoyed by all. Some people had been to the cinema. Several people attend social clubs in the evening. There was information to show people went shopping and out for lunch. Some of the people who live at holland Street said they enjoyed playing cards and games with staff. One person had been to a football match. Several people said they watched films and enjoyed listening to their own music or T.V. One person confirmed they enjoyed their weekly church visit. Records looked at for people who could not easily communicate their interests showed some activity took place during the day whether this was a trip out for coffee or shopping. Some entries showed people looked at catalogues or watched television. There did not seem to be any information as to how they are supported to lead a lifestyle that enables them to become part of the local community. There was no information to indicate whether options were reviewed for example if a day placement or college could be considered or whether there is an established daily plan for people to engage in. Discussions with some of the people living at Holland Street showed variable responses. One person was pleased with their varied activities. Two people said they would like to go out more and some people said the staff spent time with them talking watching films and sometimes shopping or going out for coffee or a walk. Information from the AQAA states that each person has an Individual Service Statement that identifies their social and leisure interests. Five of these were looked at. Two of the five ISS had no social interests identified. The other three had social interests identified but it was not clear what the frequency of these opportunities would be. Staff said that they monitor the activities to ensure people are having opportunities. However if the interests of people are not recorded then this system will not work to improve peoples lifestyle choices. Consideration needs to be given to the wishes and choices of all of the people living at Holland Street. The system for checking and improving lifestyle choices for all people is not always evident. In comparison some people have a busy social programme. From sampling records and from talking to the people living at Holland Street and their families it is evident that they are supported to maintain important personal and family relationships. This is through visits from and to their family and friends, telephone calls and overnight stays at home or going out for the day with them. The main kitchen is a commercial kitchen which people do not access due to health and safety, however there are small kitchens where some people who are able to were observed making themselves drinks when they wanted to, and washing up cups. Some of the people are in the minimal care unit and are supported to develop independent living skills. Staff said this involved making shopping lists shopping for food and preparing and cooking their meals. This was said to be part of their ISS and care plan. Discussion with staff confirmed that they had a good understanding of what support these individuals needed in relation to skills development and also in maintaining a healthy diet. Care Homes for Adults (18-65 years) Page 20 of 48 Evidence: Individual eating habits and preferences set particular challenges for staff in ensuring they get a healthy and balanced diet. One care plan identified the importance of checking this person has regular meals. A recent incident showed a meal was left out for an individual but no arrangements had been put in place to ensure the person was supervised or prompted to eat. Staff must ensure that they implement the care plan. The inspector observed three mealtimes over the four day visits. One person case tracked received support as identified in their care plan and in accordance with guidelines provided by the dietician. This included build up foods and food and fluid monitoring was evident on this persons file. Discussion with his relative identified that these records were in the main consistently kept and provided a useful overview of what the person had eaten. Discussion with staff and the relative showed that the support to the individual varied. Some staff prompted and supervised at mealtimes whilst other staff supported the person hand over hand. This person is prone to refusing foods and staff said they try all approaches to see what works best. The relative said the person eats independently. There has been staff changes which inevitably affect how well some individuals respond to staff that they may not know well. Staff was observed providing full support at mealtimes to some individuals who were supported in their wheelchair. Staff provided one to one support at a pace that was comfortable. Most of the staff interacted well during the meal encouraging individuals. One or two staff seemed rather more subdued and there was little verbal encouragement or interaction from them. The specific support and approach adopted for people at mealtimes needs to be clearer in their care plan so that there is consistency in meeting their needs.. Some comments were received from relatives about the quality of the food. These varied from meals being good to meals being poor. A discussion with the cook who had only worked in the home for two days confirmed that a choice of meals is on offer each day. Some people require liquidised or blended foods. The menus were not inspected although comments indicated that mince meat was used frequently. There was a good supply of fresh fruit and vegetables and a plentiful supply of yoghurts. People who live at Holland Street said that if they wanted something different this would be cooked. On one of the days an omelette was asked for and provided. The meals served on the days of the visit were well presented and plentiful. Two of the people commented they liked the food. One person said they discuss meals at the residents meetings but that the meals are not always good. Care Homes for Adults (18-65 years) Page 21 of 48 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of effective monitoring of health care needs raises serious and immediate concerns. Equipment which is provided to support people may not be maintained and not all staff is trained to use equipment safely. The procedures for safekeeping of medication have not been robust. These unsafe practices place people at risk. Evidence: The people who live at Holland Street had been well supported with their personal care. Their appearance was generally good and clothing was clean and appropriate for time of year. Care plans looked at gave some information about how people should be supported with their personal care needs. One relative was pleased that the detail in this reflected the usual routines and support needs of her son. Records sampled showed that health professionals are involved in the care of individuals. There was correspondence on files to show people attend regular health care appointments in line with their needs. Staff spoken to showed an awareness of specific health care needs such as diabetes and epilepsy. They were able to say how these are managed for each individual but there are some gaps in the written records Care Homes for Adults (18-65 years) Page 22 of 48 Evidence: to support this. When asked for information staff looked in care plans and individual service plans. Some information was found in health action plans. It is important to update information in the health action plan so that there is one record that holds all the healthcare information this will enable staff to meet individual health needs. Two of the five files looked at identified serious concerns regarding the lack of effective monitoring of peoples health care needs. For example one person who has diabetes requires nail care and weight monitoring. These are two key features of her care needs. The weight record showed the last weight entry was dated July 2008. The food monitoring records showed staff is recording what the person eats but they are not weighing the person regularly. This means they cannot identify quickly any weight loss. This person also needs regular filing of finger nails to ensure there are no breakages. This could pose a risk of infection which for someone who is diabetic could cause further health complications. The nail record had not been completed since 5th January 2009. A discussion with the relative identified that complaints had been made about health care needs not being monitored effectively. The complaint record showed this was investigated in October 2007. The outcome of this was that a monitoring system be implemented to monitor weight as the person had lost half a stone at that time. It was also decided that nail care monitoring be implemented to ensure regular filing of nails. It is concerning that the monitoring of health care needs in relation to this person is poor. It has been expressed that the consistency in meeting these needs is poor and records reflect this to be the case. On the day of the visit nail care was again the subject of complaint. The records demonstrate that there is little or no evidence that regular health monitoring takes place. When concerns have been expressed there is little to indicate that Holland Street is able to sustain these practices. A second file looked at showed the person needed support to maintain a healthy body weight and is a risk of weight loss. The weight record showed that weight checks had not been carried out consistently. Where weight loss was evident there were no comments or action recorded to show what steps staff were taking to follow up the weight loss. The monthly reports where the home audits its own practice highlighted concerns about weight loss in September 2008. The weight records show that although concerns about weight loss had been identified steps were not taken to consistently monitor this. The system in place for monitoring weight loss is inconsistent and could place people at risk of further health complications. The lack of weight monitoring has been a feature of other inspection reports and indicates the home has failed to sustain good practice in this area. Continued poor practice could potentially be viewed as neglectful Care Homes for Adults (18-65 years) Page 23 of 48 Evidence: or abusive. During the course of the visit two other concerns were raised by families. These related to the management of epilepsy and the management of constipation. In the one instance a monitor was missing from the bedroom. The family stated the manager on duty was unaware that a monitor should be in place. This was discussed with the Team Manager who agreed written guidelines for the management of epilepsy needed to be reviewed. Monitoring records were in place for a person at risk of constipation. Medication records showed the person had medication to support them in this area. The entries showed a period of constipation. It was positive to hear from the family that a review had been arranged to discuss this with the manager. Unfortunately the review was cancelled and this now needs to be re arranged to ensure there is effective monitoring in place. Some people require the use of equipment such as hoists to move them safely. Some staff said they had completed manual handling training. The staff training folder showed that manual handling training had not been completed by all staff and this is needed to ensure staff can support people safely and use hoisting equipment safely. The service record for equipment was not available. There was no record to show that regular checks are carried out to see how staff uses equipment to ensure they are using it safely. Staff said the manager carried out all the health and safety checks. The manager was on long term sick leave. In order to ensure equipment is safe to use an audit must be carried out to ensure all equipment is up to date with servicing. Training for all staff in moving and handling is needed to ensure they support people safely. Medication is supplied to the home in blister packs. This means that the pharmacist supplies medication in a sealed named pack. Observation of the medication being administered showed it was given at the right time and signed for by staff. Medications are secured in two medication trolleys each in a locked room. There was a photograph of the person so that unfamiliar staff would know who to give the medication to. Some people are prescribed as required PRN medication. There was written guidance to tell staff under what circumstances the medication may be used. One concern was identified regarding medication. A relative said she had found medication in the bedroom on the wardrobe. This was discussed with the senior staff and records looked at. This was identified as a tube of cream. The senior staff did not know why it was not returned to the trolley as per the medication procedures. This could put people at risk of ingesting medication or not having medication as prescribed. Staff must follow procedures when administering medication and ensure medication is secured. There are several areas of the practice that show efficient systems are not in place to Care Homes for Adults (18-65 years) Page 24 of 48 Evidence: ensure that people receive effective healthcare support. There is little evidence that regular health monitoring takes place. Equipment which is provided may not be maintained and not all staff is trained to use equipment safely. The procedures for safekeeping of medication must be followed so that people are not at risk. Surveys returned by relatives and discussions with them reflect that there has been ongoing concerns regarding the consistency of health care monitoring. They have expressed confidence in staff ability but feel the staffing levels and lack of effective management has compromised how well needs are met. It was recommended at the last inspection that all staff receive training in relation to diabetes. Information from the AQAA says staff has had this training. Records sampled included accident and incidents and showed that some people had had falls or injuries which were unexplained. This included an injury to an arm and blisters to a wrist and thumb. This was not always recorded in the health action plan so that it was clear what health concerns had taken place and whether the support people need is appropriate. As a result of these concerns three immediate requirements were made to improve the way health care monitoring is managed. Immediate requirements are what the home must do quickly to make sure people are cared for properly. The home was asked to review the health action plan to include guidance from the diabetic nurse. The plan must detail specific needs and how these will be met. The frequency of monitoring must be recorded to ensure consistency in this area. An immediate requirement was made for nail care monitoring to be implemented to ensure regular filing of nails. An immediate requirement was made in relation to weight monitoring. All individuals identified as needing weight monitoring must have a current weight recorded. The monitoring of weight must be robust. The frequency of weight checks must be determined for each individual and a system in place to record what action is to be taken where a person has lost or gained a significant amount of weight. This is to ensure that the health needs of the people living there are met. A follow up visit on 3rd March 2009 showed these concerns have now been addressed. Holland Street has identified all those individuals who require weight monitoring and have obtained a current weight. The weight record now specifies how often the person should be weighed and what to do if weight loss is identified. A review of the health action plan to include guidance from the diabetic nurse has taken place to ensure the current plan meets the needs of the individual. A record for nail care monitoring has Care Homes for Adults (18-65 years) Page 25 of 48 Evidence: been implemented. Whilst the immediate concerns have been addressed practice in these areas must be monitored to ensure consistency. These areas will continue to be monitored on subsequent visits to the home. Care Homes for Adults (18-65 years) Page 26 of 48 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people are disillusioned with the homes ability to resolve their concerns. There are a number of complaints about the same issues which the home has not resolved satisfactorily. There are serious doubts about the ability of the home to safeguard people and follow the procedures that are in place to protect them. Evidence: In the past twelve months the home has struggled to have a full management team in place and it appears this has been instrumental in resolving complaints and maintaining consistency in meeting the needs of individuals. The complaints procedure is available in an easy read format making it easier to understand how to make a complaint. Some of the people living at Holland Street cannot communicate verbally so would have to rely on others to do this. Some people living at Holland Street know how to make a complaint or raise a concern and said they would usually say this in the residents meetings. An advocate is also available to some of the people to represent their views. The advocate had concerns about the ability of the home to act on some of the concerns raised. During the course of this inspection four families and an advocate were spoken with at length. Family members spoken with are aware of how to advocate on behalf of their Care Homes for Adults (18-65 years) Page 27 of 48 Evidence: relatives and have done so. All had concerns about the ability of the management team in running the home. All of the families had regularly raised concerns and made complaints directly to the home and to the Commission regarding these concerns. There are examples of where the same concerns have been raised on more than one occasion. Concerns have been raised about the lack of care and poor monitoring of health. Staffing levels and the use of agency staff has also caused concern and generated complaints. Parents stated that when action was taken to rectify these it was never consistent. Families and the advocate raised concerns about the ability of the home to keep people safe. Some people commented that they were reluctant to raise concerns because they were not received well by individual staff members however they also identified staff they did have confidence in. One recent complaint related to a breach of confidentiality and intimidating behaviour. This is under investigation but raises questions about the ability of some staff to ensure confidentiality. Discussions with parents clearly indicated that they have little confidence that the home can improve outcomes for the people living there because they raise the same concerns time and again. The complaints file showed that the Team Manager has responded to complaints and taken action to improve outcomes. However there is a pattern emerging which suggests that improvements are not sustained. The monthly visits by the providers representative show that complaints are monitored on a monthly basis. Some attempt has been made to improve outcomes. The rotas were adjusted to improve the skill mix of staff on duty so that people receiving care and support has staff that know their needs. There was also an example of a concern about the risk of falling. Some time had elapsed before action to minimise this risk had been taken. It was not evident from training records that all staff had up to date training in adult protection and the prevention of abuse. A recent safeguarding incident highlights a serious lack of effective management in relation to protecting people. Minimum staffing levels were not maintained. The wing that the person lived on was unstaffed for a period of time and no arrangements had been put into place to cover this absence. The team manager said that there were staff shortages that day as two staff did not arrive. These events left vulnerable people without the support they needed. The missing person procedure was not followed. Daily reports were not completed for that day therefore there was no record or alert about the length of time the person had been out of the building. There was poor communication between staff going off shift and the duty manager. There are discrepancies about what information was Care Homes for Adults (18-65 years) Page 28 of 48 Evidence: passed on and there was no written record of this. This practice puts people living at Holland Street at risk. The ISS looked at for the individual contained a risk assessment for going out independently. This stated to be aware of his whereabouts. There was no detail or instruction as to what this meant such as what checks needed to be carried out or what to do if the person does not return. No checks had been initiated to see if the person was in the building. The care plan highlights a preference for spending time alone in the bedroom. There was no specific guidelines as to how often staff should check on the individual. There appeared to be no regular checking on the upstairs wing which was unstaffed and this would leave vulnerable people at risk. The absence of staff and records adds to the likelihood of poor supervision and monitoring within the home which heightens the risks to people. The management are aware of the procedures for notifying the Commission of events that may affect the welfare of people living in the home. On this occasion no notification of this event was sent. This is extremely worrying. The fact that this incident was not recognised or reported as a safeguarding incident until the advocate did so raises serious doubts about the ability of the home to safeguard people and follow the procedures that are in place to protect them. Requirements are made in the key inspection report to review and develop the safeguarding procedures to ensure all staff knows what to do should an incident occur. The procedures for reporting incidents need to be robust including passing on concerns to the Commission via regulation 37 notifications. Training records did not evidence all staff were up to date with adult protection training and a requirement is made to ensure this training is undertaken and a record maintained. Since this incident a protocol has been developed for alerting the family and other agencies of such an incident and also to guide the staff in the steps to be taken. However there are missing persons procedures within the home and there is a need for staff to follow these to ensure the safety of individuals. Care Homes for Adults (18-65 years) Page 29 of 48 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some improvements have been made to provide a comfortable environment for people to live in. There are potential risks to people such as excessively hot water and poor fire safety checks. The lack of consistent checks and follow up action means the service cannot be sure people live in a safe environment. Evidence: The provider has informed the Commission that the home will re provide its service. The home is arranged over four different living areas these are known a wings. On the first floor people are supported to live more independently this part of the home is referred to as minimal care. The ground floor accommodates people with additional physical disabilities. At the previous inspection in January 2008 some improvements in the environment were underway. Priority had been given to decorating some of the bedrooms downstairs and the dining room. The lounges areas and the activities room were included in this plan. Information from the AQAA and observations made confirmed that these Care Homes for Adults (18-65 years) Page 30 of 48 Evidence: improvements had been made making it a nicer place for people to live in. Those bedrooms and communal areas seen were clean and comfortable. Some of the people living at Holland Street said new furniture had been bought. People were generally happy with their bedrooms and had the items of furniture they needed. The bedrooms had personal possessions in them and were nicely kept. Although the bedrooms are small no one complained about lack of space. One person case tracked has some mobility difficulties which means her bedroom needs to be kept tidy to lessen the risk of falling. Her room was viewed to be tidy and had a variety of personal possessions evident. Her relative said that at times there are books or objects on the floor and that some staff are better than others at keeping the room obstacle free. The small lounges on the ground floor were tidy and clean with no obvious hazards. Furnishings were comfortable. Some areas of the home lacked soft furnishings and so looked a little bare. Some areas of the home appear not to be as well utilised as some people prefer one lounge to the other. The people living at Holland Street said that staff helped them to choose the colour for their bedrooms. Some people actively clean their own bedroom and make their bed. The bathroom and toilet areas were clean and functional and offered sufficient space for supporting people who required assistance. There is a small kitchenette on the ground which some of the people access to make drinks. This area was clean and functional. Water temperature records were looked at and showed that the water was running too hot. This could pose a risk of scolding. The record was shown to the senior care staff who said they did not know why this had not been reported. A visit was made to the kitchenette where the two taps were hand tested and found to be too hot to keep a hand under. An immediate requirement was made and the senior care was asked to call the engineer to rectify this. This was done that day with confirmation sent to the Commission. A faulty valve was replaced so that the water could be regulated. It is of a serious concern that staff are testing and recording water temperatures but not acting upon the outcome of this to ensure people are not placed at risk of scolding. Water checks must clearly show what action has been taken to maintain safe water temperatures and prevent the risk of scolding. Staff should sign the record to show what steps they have taken to keep temperatures safe. Fire records were checked to ensure regular testing and service of equipment take place to protect the safety and well being of people living at Holland Street. During the course of the visit serious concerns were identified. Fire alarm testing and recording was not consistently carried out. Records showed overlong gaps between testing. Consequently on some of these occasions the alarm was not tested for a period of two weeks which means potentially any faults in the system would go undetected and could lead to serious harm to people living and working at Holland Street. Care Homes for Adults (18-65 years) Page 31 of 48 Evidence: Testing of the emergency lighting was not consistent and could place people at risk of harm. Records of fire drills did not reflect that regular six monthly drills are carried out and recorded to ensure staff knows how to evacuate people safely in the event of a fire emergency. A record named as instructions and drills was evident but this did not constitute appropriate fire drill or fire instruction. The staff was unable to locate the most recent fire officer report to check if recommendations had been met. The fire officer report when located showed there were serious fire safety measures to be addressed. These had not been followed up. Potentially the risk of people living in the home coming to harm is high. An immediate requirement was made and a warning letter sent to the provider so that these areas of concern could be attended to urgently. This is to ensure the home complies with the law and safeguards the people who live at Holland Street. The Commission received confirmation from the provider that these immediate requirements had been met. A follow up visit to Holland Street on 3rd March 2009 confirmed that the immediate safety concerns relating to fire measures had been resolved. The provider must continue to ensure that fire safety tests are carried out as required. The domestic cleaner described the cleaning routines and was aware of keeping hazardous substances such as cleaning products safely locked away. The home was clean and there were no offensive odours. The manager had taken appropriate action to follow up a leak in the lounge area where work was in progress to repair this. Care Homes for Adults (18-65 years) Page 32 of 48 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels do not always meet the needs of the people using the service which has affected their welfare. There is no comprehensive training plan and much of the training is out of date. This could impact on the wellbeing of the people living there. Recruitment procedures ensure people who live at Holland Street are protected from anyone considered to be unsuitable to work with vulnerable adults. Evidence: At the previous inspection concerns about the number of staff vacancies and the impact of using high numbers of agency staff had been addressed. Five new staff some of whom had already worked at the home on a casual or agency basis and were familiar to the people they cared for had been appointed. At this inspection staffing arrangements had changed. The staff team is made up of agency staff and permanent staff. Some additional staff from Lifeways were also working in the home. During the four visits to the home there were different staff compilations. On three visits agency and permanent care staff were on duty. On one visit new staff from Lifeways as well as additional staff from the day centre were present. On two occasions the day centre was closed and so most of the people living at Holland Street were at home. Observations made were variable. Staff engaged with Care Homes for Adults (18-65 years) Page 33 of 48 Evidence: people in activities such as art and crafts and a cinema trip. On two occasions no activities were evident. One wing was empty of staff for at least ten minutes. Two people sat in their wheelchairs at the table whilst staff attended to another person in the bathroom. Parents and carers expressed concerns that some but not all agency staff spent little time interacting with people and did not know their needs. Records showed that this had been raised with the home and that appropriate steps had been taken to adjust the rota to provide a more suitable mix of experienced and skilled staff. Attempts had been made to improve the staffing mix to improve consistency in meeting the needs of people. Some parents commented that staff was always writing reports and not spending time with individuals. On one visit at 11 am staff was observed sitting writing reports. There was no activities evident for the people at home on that day. The deputy stated that staff needed to write reports early in the shift to ensure they were completed. There needs to be a better balance between tasks and provision of care. Surveys returned by parents had varying comments regarding the staff team. Some stated they had confidence in the staff team members. One parent commented that a fair proportion of staff is good but that the same could not be said for all of them. Another survey commented on positive personal care but a lack of continuity. Most surveys and discussions with parents indicated that more interaction and stimulation was needed. Parents felt that most of the staff delivers a good service under difficult circumstances. They also commented on declining staff levels. Throughout the inspection some staff was observed to interact positively with the people. They asked people what they would like to do and spent time talking to them. Staff was attentive to needs and took time to make people comfortable. One staff member was observed supporting a lady out of her wheelchair as the strap was tangled. She made adjustments to the strap and seated her safely. She communicated throughout so that the person understood the delay. Various mealtimes were observed and staff appeared attentive and supported people with their eating. It was evident from discussions with a variety of staff and observing their practice that most staff are respectful as well as approachable. They listened and communicated well with the people they were supporting. Some staff did not communicate or interact so well. Some of the people who live at Holland Street spoke positively about staff and others were seen to gravitate to staff they felt comfortable with. The AQAA showed that the over fifty percent of the team had achieved NVQ level two or above. This should ensure the staff team have the skills and training to ensure Care Homes for Adults (18-65 years) Page 34 of 48 Evidence: people are in safe hands. There were sufficient numbers of staff to see to the needs of people. However rotas showed staff shortages had been evident. On occasions senior staff had worked as the sixth staff member on shift which put additional pressure on them to complete their managerial duties. Some staff stated there was never time to reflect or plan ahead as often only one manager was on duty. Staff members said sometimes staff levels fell below the minimum level due to people not turning up for their shift and having difficulty in finding replacements at short notice. Staff at all levels said they try to resolve concerns and improve practice but recognise that monitoring of standards is compromised at times because of the staffing levels. Staffing levels have adversely affected the welfare of the people as explained in the complaints section of this report. The personnel department carry out recruitment checks. Four staff files were sampled and showed that all had the required information. This ensures people who live at Holland Street are protected from anyone considered to be unsuitable to work with vulnerable adults. Improvements had been made regarding staff training at the last inspection in January 2008. The training records at that time showed that a lot of mandatory training had taken place or was booked for all staff with the exception of diabetes. At this inspection information about training was looked at to ensure staff had the skills to meet the needs of the people at Holland Street. This information showed gaps in mandatory training for both agency and permanent staff. Not all staff had up to date training in Epilepsy or Fire Safety. Training in Dysphasia and Manual Handling was not completed by all staff. Most staff had Diabetes training which means they have a good understanding of the implications of diabetes and how these should be managed. Training in Manual Handling appeared to be the biggest deficit and this is required to ensure staff can support people safely and use hoisting equipment safely. There are some people who live at Holland Street who require a great deal of assistance with their physical care needs. All staff regardless of their rank or role is required to undertake manual handling training to ensure they know how to move and support people safely. Once this training is completed regular refresher training should be undertaken. The training records indicate that not all staff has up to date training in this area and there is no record of refresher training. Senior staff should have a system for monitoring and supervising staff in the use of equipment to ensure they are using it safely and to identify any training gaps. This ensures staff are able to follow the care plan instructions for each individual and know exactly what equipment they use and how to use it safely to minimise any risk. Care Homes for Adults (18-65 years) Page 35 of 48 Evidence: The training record for Lifeways staff was up to date. There was no training matrix that could show the whole teams training. The AQAA did not provide any training updates except on diabetes in house training. In order to ensure all staff is up to date with their training the home should develop a matrix of the staff performance across both mandatory and specialist training. This must be completed and kept up to date to ensure that staff has the skills to care for people appropriately. Staff said they used to have staff meetings every two weeks to pass on information about the needs of the people living there and discuss any problems or issues. Staff said they do not have staff meetings but use the handover to discuss any issues regarding the care of the people living on the individual wings. There should be regular staff meetings to allow for the participation of all staff. Care Homes for Adults (18-65 years) Page 36 of 48 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has been without a manager and a depleted management team for a period of time. The consistency of meeting health and safety requirements and closely monitoring its own practice has deteriorated. Improvement is needed so this does not result in people being put at risk. Evidence: The manager is qualified and has the necessary experience to run the home. She was not present for the full inspection of the home. The management team has been seriously depleted due to sickness of its members including long term sick leave of the manager. In the past six months the home has struggled to have a full management team in place. There has been a serious lapse in monitoring the care practice and ensuring compliance with safety procedures. Training and supervision of staff has been variable. Not all staff has had sufficient or recent training to enable them to work safely. Care Homes for Adults (18-65 years) Page 37 of 48 Evidence: Records show there has been incidents resulting in injuries which were not witnessed. This included blisters to the hand of one person and an injury to the elbow resulting in hospital treatment. One person had been missing from the home unnoticed for several hours. Not all incidents have been appropriately notified and it is concerning that people are getting hurt. Parents and the advocate have expressed concerns and have little confidence that people are always cared for in a safe way. Several relatives have expressed ongoing concerns about the lack of management saying that they feel communication is sometimes poor. There is concern amongst parents that things take a long time to get done and that the response is often short term. It is acknowledged that this is a very difficulty and challenging time for any manager as permanent staff is redeployed requiring the service to adapt to constant change. However it is unacceptable that health and safety and other procedures that are in place to protect people have not been fully implemented. To ensure the health and safety of the people who still live at Holland Street there must be a clearer delegation of tasks so that important checks are carried out. A representative of the provider has visited the home monthly to audit the service provided to the people living at Holland Street. Reports sampled showed that they have looked at some areas and made recommendations to improve the service. However the findings indicate that the home is struggling to deliver a service. Quality assurance systems have not been developed any further since the previous fieldwork visit. The service should aim to reflect in their quality assurance what improvements they are making in response to the concerns people have raised. This would help them to develop the system as a management tool. During the four visits made to Holland Street three senior staff and the deputy were spoken with. Whilst the senior staff were receptive and helpful it was evident that they did not always know who was doing what or where to find information. Senior staff said that they carry out regular audits such as the frequency of accidents and health and safety testing. However basic safe practices regarding fire safety and water temperature safety has not been robust. The lack of health care monitoring has also lapsed. This indicates the systems that are in place are not working for the benefit of people living there. There is a communication book and a handover between shifts to allocate tasks and promote continuity. This has been hindered by the gaps in the management team due Care Homes for Adults (18-65 years) Page 38 of 48 Evidence: to sickness. On occasions only one senior has been on duty and this has made it difficult to support staff on the different wings as well as carry out their daily management tasks. Senior staff stated that the manager dealt with health and safety checks but the rotas show the manager had been off sick for a number of months. There was no clear delegation of health and safety checks and no information presented to indicate if other equipment used in the home had been serviced. The Annual Quality Assurance Assessment AQAA which is completed by the manager prior to the inspection was incomplete. It did not provide evidence that all safety checks had been carried out. There was no date of the last hoist check or electrical wiring. The lift service was dated 2007. The AQAA gives very little information about the service. There is minimal evidence to support the claims made within it. For instance they state managers maintain consistency on each shift by checking tasks have been completed. The example of the missing person indicates this is not happening. The AQQA states that managers are allocated specific tasks and allocated to areas of the home to ensure the smooth running of the home. The lack of safety checks relating to fire and water temperatures indicate this not to be the case. The monitoring of weight was not consistent. The AQAA stated that they maintain adequate staff numbers but rotas and discussion with staff show this not to be the case. The daily handovers are said to be used to ensure good communication so staff are aware of people and their needs. The missing person incident showed these processes can not be relied upon. There was no information to show when policies or procedures were last reviewed. This could compromise safe working practices. The lack of good monitoring and recording could compromise safe working practices in the home. There must be a robust record of all safety checks to ensure people are not at risk. As a result of concerns identified during this inspection four immediate requirements were made. These are things the service must do immediately to ensure concerns are resolved. A warning was sent to the provider confirming the action they needed to take. The Provider has met the immediate requirements within the timescales provided. These related to the lack of effective weight monitoring and poor care planning for health care needs. The lack of fire safety records and safe hot water temperatures also required immediate attention. In order to ensure health and safety procedures are robust a further requirement is made to audit the equipment used in the home to ensure all equipment is up to date with servicing. A plan must put in place identifying the frequency of tests. There needs Care Homes for Adults (18-65 years) Page 39 of 48 Evidence: to be a clearer delegation for monitoring amongst the senior staff team so that in the event a designated member is absent this can be picked up quickly and managed appropriately. The lack of safe testing and servicing could put people at risk and the service cannot be confident that all the working practices in the home are safe. Whilst progress has been made on meeting the immediate requirements the provider must now ensure that improvements are sustained. This will ensure that the home is well run for the people living there. During a follow up visit on 3rd march we were informed that the manager and deputy had been temporarily placed at other homes. This was concerning because the home was without a manger and there were serious concerns that needed to be addressed. This was discussed with the provider who took prompt action to appoint a temporary manager and deputy with the management skills and experience to run the home. Any change to the interim management arrangements should be notified to the Commission. Holland Street has failed to provide good outcomes for people. It is important that the owner has good oversight of the areas that need development so they can ensure improvements are targeted and that the service does not drift. It is important that the service demonstrate they can both meet and sustain the requirements made. Care Homes for Adults (18-65 years) Page 40 of 48 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 19 12 (1) (a) Individuals weight must be 28/02/2008 monitored regularly and action taken where a person has lost or gained a significant amount of weight. This is to ensure that the health needs of the people living there are met. Care Homes for Adults (18-65 years) Page 41 of 48 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 There must be a prompt response to unexplained absences. To prevent people from coming to harm whilst supporting them to take risks as part of an independent lifestyle. 30/06/2009 2 18 13 Staff training is required in manual handling techniques and the use of equipment. This is to ensure all staff knows how to support people and how to use equipment safely. 31/07/2009 3 19 12 Nail care monitoring records 31/07/2009 must be completed regularly and at the frequency determined in the care plan. This is to ensure people are not at risk of infection or other health care problems related to diabetes. Care Homes for Adults (18-65 years) Page 42 of 48 4 19 12 weight monitoring records 31/07/2009 must be completed regularly and at the frequency determined in the care plan. This is to ensure weight loss or gain is monitored closely so that people are not at risk of further health complications. 5 19 12 The health care plan for the management of diabetes must be kept under review. This is to ensure people are not at risk of further health complications. 31/07/2009 6 23 13 All staff must have up to date training in safeguarding. A record of training should be available. This is to prevent people suffering harm or abuse. 31/07/2009 7 23 13 A review of the safeguarding 31/07/2009 procedures is required. This is to ensure all staff knows what to do should an incident occur. 8 24 13 To ensure the environment is safe staff must check water temperatures and take appropriate action. This is to ensure people are not at risk of scolds. The immediate requirement made on 12th february 2009 was met on 12th february 2009. The Provider must ensure water temperatures do not exceed the 31/07/2009 Care Homes for Adults (18-65 years) Page 43 of 48 recommended level to minimise the risk of scolding. 9 24 23 Adequate arrangements 31/07/2009 must be in place to ensure fire safety procedures are carried out. This must include regular testing and recording of the fire alarm system and fire drills. There must be a system in place to demonstrate fire safety training for all staff has taken place or is planned. To ensure the risk of people coming to harm is minimised immediate requirements regarding fire safety were on 12th february 2009. These were met on 10th march 2009. The Provider must now ensure fire safety procedures are maintained to ensure the safety of the people living at Holland Street. 10 33 18 There must be enough staff on duty at all times. This is to ensure people are safe and their needs are met appropriately. 11 35 13 All staff must have up to date training in manual handling. This is to ensure they can support people safely and use equipment safely. 31/07/2009 31/07/2009 Care Homes for Adults (18-65 years) Page 44 of 48 12 37 24 The manger must ensure there is a system in place to review and monitor the care practice. This is so that there is a system in place for improving the care practice for the benefit of the people who live at Holland Street. 31/07/2009 13 42 23 The manager must ensure that all and any equipment provided to support people with their needs is maintained and in good working order. An audit of equipment must be undertaken to ensure it has been serviced. This is to ensure all equipment is safe to use and not a risk to the people using it. 31/07/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 6 Care plans should be developed further so that staff support people with their personal care preferences in the way they prefer. Care plans should reflect how people are supported to do the things they want and enjoy. The decisions and choices people make should be reflected in their care plan so that it is clear they are involved in decision making. Risk assessments should state the specific risk so that people have the support to keep them safe in their activities. Risk assessments should be reviewed to ensure they are in date and have specific details about the steps to take to keep people safe. 2 7 3 9 Care Homes for Adults (18-65 years) Page 45 of 48 4 9 Risks assessments and protocols need to be developed for those people who access the community independently to ensure their safety. The care plan should clearly state the choice of activities people have made. This is to ensure everybody is able to do the things they like that are important to them. The care plan should show how those people who do not attend a day placement are encouraged to become part of the local community. This will ensure their oppotunities are increased. The care plan should describe the actual support people need at mealtimes. Staff must ensure that they implement the care plan so that people has the support they need to eat healthily. An audit of all aids and equipment used to support people should be carried out. This is to ensure equipment is safe to use. The support people need with their personal care should be clearly stated in their care plan. This should include detail personal to them such as the way they prefer their hair styled or whether they prefer a daily shave. This ensure they receive personal support in the way they prefer. The cancelled review that was arranged to discuss the management of constipation needs to take place. This is to ensure the current monitoring of constipation is effective. The home should seek to learn from any complaints it receives. A more robust review of the outcomes of complaints should be undertaken. This should reassure people their complaints have resulted in improved outcomes for people which can be sustained. The procedures for reporting incidents via regulation 37 notifications needs to improve. This is to ensure people are properly protected. All staff should ensure that they interact with and know how to communicate with the people living at Holland Street. It is important staff has positive attitudes when supporting people. There should be an up to date training matrix to reflect all mandatory training has taken place. There should be a clearer delegation of management tasks so that mangers know who is responsible for carrying out important checks to keep people safe. The manager must ensure that the home achieves its written aims and objectives so that people can benefit from Page 46 of 48 5 12 6 13 7 16 8 18 9 18 10 19 11 22 12 23 13 32 14 15 35 37 16 37 Care Homes for Adults (18-65 years) a well run home. 17 18 37 39 The manager must ensure that policies and procedures are implimented so that people live in a well managed home. Quality assurance systems should be developed further so that the views of people are sought about the day-to-day running of the Home. This should include where people have registered concerns and reflect what the home is doing to make improvements. Care Homes for Adults (18-65 years) Page 47 of 48 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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