Inspection on 12/12/06 for Alphonsus House

This inspection was carried out on 12th December 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 30 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alphonsus House 18/08/08

Alphonsus House 22/08/07

Alphonsus House 16/06/06

Alphonsus House 24/01/06

Alphonsus House 07/12/04

Alphonsus House 29/06/04

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 Alphonsus House 81 - 85 Vicarage Road Oldbury West Midlands B71 1AH Lead Inspector Lesley Webb & Mandy Beck Unannounced Inspection 12th December 2006 08:00 Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alphonsus House Address 81 - 85 Vicarage Road Oldbury West Midlands B71 1AH 0121 544 6311 0121 544 6311 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) www.craegmoor.co.uk Parkcare Homes Limited Mrs Christine Ann Priscilla Till Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Four service users identified in the variation report dated 17 August 2005 may be accommodated at the home in the category PD. This will remain until the identified service users placements are terminated at which time the category will revert to LD only. Four service users identified in the variation report dated 17 August 2005 may be accommodated at the home in the category LD(E). This will remain until such time that the service users placements are terminated at which time the category will revert back to LD only. 2. Date of last inspection 16th June 2006. Brief Description of the Service: Alphonsus House is owned by Craegmoor Healthcare and is registered to provide care for 18 adults with a learning disability. The home consists of three adjoining Victorian properties with external access between the houses via the rear garden. Each house is self contained with it’s own facilities with the exception of a communal laundry between houses 83 and 85. The home is situated on a busy main road between Oldbury and Langley. It is close to local shops, pubs and other public amenities. There are good public transport links to nearby towns of Dudley, Oldbury and Birmingham. There is a small driveway at the front of house 81 with space for one car. Car parking is on the main road outside the three properties. The home has 14 single bedrooms and four double bedrooms situated on the first and ground floors. Access to the upper floors are via a stairways. Each property contains a dining room and a lounge. There are three domestic style bathrooms and toilet. Each house has it’s own dedicated staff team although staff may work in all three houses to cover absences if required. Fees for this home range from £358.97 to £1,388.50 for each week. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this inspection over one day with the home being given no prior notice. During the visit time was spent talking to service users and staff, examining records and observing care practices before giving feedback about the inspection to the registered manager. The people who live at this home have a variety of needs. This was taken into consideration by the inspectors when case tracking three individuals care provided at the home. For example the people chosen consist of both male and female and have differing communication and care needs. No relatives of service users were present during the inspection. The home is registered to provide long term care for people by the reason of learning and physical disability. Discussions with some service users living at the home was not appropriate. Therefore observation of behaviours was undertaken in order to form judgements on care provision. A number of records and documents were also examined as well as case tracking. What the service does well: Conversations with staff and observation of care practices indicate that the home attempts to meet the needs of service users. When asking about meeting needs one member of staff replied, “ you have to get to know each person, for example if have epilepsy being aware of what might trigger and where in the building. I have also done training, which also helps”. All service users have regular check-ups with the dentist, optician and other specialists in accordance with their needs. The home has regular service user meetings that give service users the opportunity to talk about what they want from the home and what they like about living there. One service user stated, “I talk about music” another said, “I told I’m going home for Christmas”. These allow people living at the home to be involved in decision making relating to their care. Staff who work at the home said that they are encouraged to take part in training to help keep their knowledge and skills up to date. “There’s always training to do especially if you are new”. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: As mentioned in many sections of this report the home must review and amend many records relating to people living at the home. Although documentation is in place including assessments of need, care plans, risk assessments, activity records and policies and procedures, all need auditing and amending as they contain out of date information or have omissions in content. Without improvements in these areas the home cannot be satisfied it is meeting all needs of people living at the home. Further work must be undertaken to ensure people living at the home can participate in activities outside of the home at weekends. Currently there is no allocated driver of a weekend and this restricts choice for service users. Work must also be undertaken by the home to demonstrate people living at the home receive choices of meals. There are menus in place but these do not offer choices. The majority of service users have hourly checks completed through the night. This was discussed with the manager as no evidence supporting this practice could be found for some people. The manager stated that for some people this does not mean that staff go into their bedroom, but that they listen outside of the door. The inspectors instructed that records accurately reflect this and that records also be put into place demonstrating for those who require visual Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 7 checks that it is in the person’s best interest and that their privacy is not compromised. The home is not suited to all of the needs of the service users, some service users struggle to move around the home due to the narrow corridors and doorways and limited wheelchair access, the home must consider how it is going to ensure it is complying with the Disability Discrimination Act. The home needs to increase the amount of staff with a National Vocational Qualification so that they can be sure all staff have the skills and knowledge to care for the service users who live at the home. The manager must arrange refresher training for staff to make sure that their knowledge of adult protection and infection control is up to date and being practiced in away that protects service users. The way that the service finds out if they are providing quality care to service users needs to be reviewed so that all service users participate in this process and the home will be assured that they are acting in service users best interests. There needs to be an improvement in record keeping of safety checks such as fire extinguishers, fire/smoke detectors and fire drills. This will ensure that service users welfare is promoted at all times. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments are completed for people. Further work is required to ensure staff that undertake this task are suitably qualified in order that the home can be confident all needs are identified and planned for. EVIDENCE: All service user files that were sampled contained assessments of needs. The contents of these however varied in terms of accuracy, detail and relevance. For example one persons file contained an assessment for outcome based evaluation for learning difficulties that has been part completed, another that contained an assessment stating the person ‘suffers with mental health problems’ when this person has no formal diagnosis of this condition and a third persons file contained assessments that are no longer applicable due to changes in circumstances. A requirement was made at the last inspection that staff must be trained to the level of skills required to assess the needs of the client group living at the home. This requirement remains unmet. This was discussed with the registered manager, who stated she did not understand the requirement as assessments are only completed by social workers and her. The inspectors explained that all files sampled contained assessment documentation completed with involvement of care staff within the home and that evidence from these suggests they do not have the Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 10 appropriate knowledge or assessment processes, terminology and report writing. For example as mentioned one service user has assessments that state he has mental health problems. When the inspectors investigated this (due to the home not being registered for this category) the service user in question has been diagnosed with autism, which is not a mental health condition. It was also noted that many documents are referred to or titled care plans when they are assessments, indicating staff do not fully understand the difference between these processes. Conversations with staff and observation of care practices indicate that the home attempts to meet the needs of service users. For example one service user in is the process of being found alternative accommodation due to changes in needs that the manager recognises cannot be met by the home and another service user was witnessed moving to another room that has become vacant due to this being more appropriate for wheelchair use. When asking about meeting needs one member of staff replied, “ you have to get to know each person, for example if have epilepsy being aware of what might trigger and where in the building. I have also done training, which also helps”. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work is required to ensure care planning and risk assessment processes are clear and consistent, providing staff with the necessary directions of actions required. Generally service users are supported to make decisions for themselves to maximise their independence. EVIDENCE: All files sampled contained care plans that have been generated from initial needs assessments. The inspector found that the contents varied and do not always demonstrate how needs are managed. For example for service users who have been identified with additional needs such as communication, epilepsy or behaviour, care plans are either missing or lack detail, specific aims or goals and in some cases corresponding risk assessments. All files contain evidence that the home reviews its care plans but the majority of those sampled state that no changes have occurred despite other documentation evidencing changes of needs. All files did however contain Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 12 evidence that regular meetings occur between service users and their key workers. The inspector recommends that staff receive further guidance regarding the minutes of these meetings as the majority read as a statement about the person and not as an overview of the previous months events. Person centred planning is not in place at this home, with staff confirming they have not received training and that they do not understand this concept. For example one person stated when asked about this, “not sure, is it to do with activities”. The manager confirmed this has yet to be introduced to the home. Observation of care practices, discussions with service users and viewing of documentation demonstrate that attempts are made to involve service users when making decisions about their lives. For example service users were observed being asked their opinions by staff and records confirm that regular service user meetings now take place. As with care planning risk assessments are in place but further work must be undertaken to ensure these are in place for all identified needs and that they work in conjunction with relevant care plans. It was noted by the inspector that a document titled ‘infringement on rights’ is on service users files that makes reference to risk assessments by number. When investigating this the inspector could find no risk assessments relating to the infringement. This was discussed with the manger who was not aware of this document or risk assessments, stating that she thought it was an old document. The inspectors recommend that an audit of service users files be undertaken with any items that are no longer relevant or out of date being archived. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work is required to ensure service users are assisted to pursue personal development and a range leisure activities. The involvement of family and friends is encouraged in agreement with the service users wishes. Meals at the home appear wholesome. Further work must be undertaken to ensure service users are offered choices and are actively supported in menu planning. EVIDENCE: Observations made during the visit confirm that in the main service users routines are flexible. Service users were observed moving around the home freely, choosing where to sit and who to interact with. Some efforts have been made to introduce independent living assessments and care plans to support people develop life skills, however further care must be taken by staff to ensure the contents of these are adhered to. For example one persons plan states, “need assistance, staff to remind me to Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 14 wash my hands and wear personal protective equipment when in the kitchen” this service user was observed in the kitchen with staff but non were seen following the actions of the plan. It was also noted that despite this staff recorded that they were ‘compliant’ with the plan during their shift. A weekly activity planner is in place that detail events such as attendance at day centres, placements and in-house activities. Further work is required to develop the activity planner so that planned activities in the community take place on a regular basis. For example to planner makes no reference to activities such as daytrips, the cinema, bowling, public houses, restaurants ect. Of a weekend it states ‘service user choice’ when this was investigated the inspectors found that choice is restricted as there is no allocated driver on duty of a weekend, which restricts what activities can take place. Records indicate that very little off-site activities take place at weekends. It was also noted that some choices raised in service user meetings have not occurred with no written explanation as to why. When assessing activities the registered manager confirmed that some service users have not been on holiday this year. She informed the inspectors that this was due to behaviours that would not be appropriate in settings such as a hotel. The inspectors instructed that if this was the case it should be reflected in their care plans and alternatives sought. They also advised that if daytrips are thought to be more appropriate these should be above what is arranged for anyone else, with finances allocated equivalent to that of an annual holiday. Menus viewed indicate that service users are not offered at least 2 choices of a main meal each day. The inspectors instructed that choices must be included in the menus and not be in reaction to service users not wanting the meal of choice for that day. Each file sampled contained a document that states ‘consult on weekly menu and evidence must be recorded on reverse of the menu indicating the methods used in assisting the service users in making choices’. No evidence of this occurring could be found. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally staff respect service users privacy and dignity and give personal support to achieve this. Healthcare needs are adequately managed, however some improvements to health records are required to ensure effective monitoring is achieved. EVIDENCE: Observations and examination of records confirm that in the main service users privacy and dignity is respected. For example staff informed the inspectors of service users who were in a state of undress in order not to compromise their dignity. Service users are able to see medical professionals in the privacy of their own rooms. It is recommended that an audit of service users files take place and all old documentation be archived. For example some files contained a document that states personal care may have to be given to female service users by male employees. The manager confirmed this was not the case, agreeing that this should be removed. It was also noted that the majority of service users have hourly checks completed through the night. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 16 This was discussed with the manager as no evidence supporting this practice could be found for some people. The manager stated that for some people this does not mean that staff go into their bedroom, but that they listen outside of the door. The inspectors instructed that records accurately reflect this and that records also be put into place demonstrating for those who require visual checks that it is in the persons best interest. Records seen by the inspectors demonstrate that the service users health needs are monitored by the home, with appropriate referrals made when required. All service users have regular check-ups with the dentist, optician and other specialists in accordance with their needs. A requirement identified in the last inspection instructing that the policy on ageing and illness which advocates staff discussing the benefits of will making with service users must be reviewed remains unmet. The manager confirmed that no progress to amend this has yet been made. All service user files that were sampled contain medication assessments. When looking at these the inspectors found that some contain conflicting information. For example one persons assessment states ‘is knowledgeable on the correct time to take his medication’ but on another states is unable to self medicate. No one living at the home is currently managing his or her own medication. The inspectors recommend that service users are reassessed and attempts are made by the home to support people to develop skills in this area based on their individual capabilities. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is some evidence that service users views are listened to and acted upon, however further improvements can be made. Improvements to some records will offer further protection to people living at the home. EVIDENCE: The majority of requirements identified in previous requirements relating to complaints and protection are now met. The adult protection policy has been reviewed; the majority of staff have undertaken adult protection training and some efforts have been made to comply with agreed actions identified in a previous adult protection investigation. When looking at complaints and protection policies and procedures the inspectors recommend that an audit of these be undertaken with old policies archived. Currently there are two files in circulation at the home, both of which contain out of date information. The prevention and management of physical aggression policy was viewed and found to be very detailed. When cross referencing this with care plans and other documents the inspectors found that the contents of this policy are not reflected in records currently in use at the home. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 18 Some evidence was found that indicates service users are supported to understand their rights to complain. For example files contain the complaints procedure in large print, picture format and one service user confirmed he felt comfortable to raise issues. The inspectors strongly recommend that further work be undertaken in this area. As mentioned in other areas of this report regular service user meetings take place, but it is disappointing to find that this forum is not used to raise awareness of complaints processes. The manager did however state that the home is in the process of completing a video for the service user guide that would include the complaints procedure. The inspectors recommend that a video be made separately regarding complaint procedures, as many people living at the home can understand written documents. The complaint policy was viewed and appears appropriate. There has been one complaint recorded since the last inspection that was raised by staff. Records relating to this appear appropriate. A protection of vulnerable adults folder was also viewed but found to contain no records. This was discussed with the manager who states documents relating to protection are filed in various places depending on the issue. It is strongly recommended that a monitoring sheet be introduced in relation to this for effective monitoring. When assessing if the home has complied with agreed action from a previous adult protection investigation the inspector was concerned that matters remain outstanding. An in-depth discussion with the manager and staff took place as it took over twenty minutes to locate any form of records to verify actions taken and those that were produced were not appropriate for monitoring purposes. Issues identified from the records that were produced are that some service users have not received agreed payments and one service user has now left the home before receiving the agreed amount in full. The inspectors instructed that an audit is completed and any remaining monies owed be paid direct to service users. The personal finances and records were examined for three service users. All are appropriate. Inventories of personal belongings are maintained for each person. Further work is required to ensure clear records are maintained of items destroyed and reasons why. It was also noted that staff have recorded items belonging to the home on these. The manager agreed these should be reviewed and amended accordingly. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is generally clean and tidy, however the environment does not meet the needs of all the service users. EVIDENCE: It was pleasing to see that some progress had been made in meeting the previous requirements for example for the damage to the ceiling in the bathroom (83) has been repaired. Other areas require further development, the crazy paving to the rear of house 81 has been made even to make it wheelchair accessible however there is no ramp for service users to use to get out into the garden, this means that the garden area remains inaccessible for service users unless staff assist them. There is a large amount of rubbish to the rear of house 85 that must be removed. The manager did state that they are waiting until they have enough rubbish to be able to order a skip to remove it all. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 20 A partial tour of the premises was undertaken and some service users bedrooms were seen with their permission. It was noted that some of the duvets and pillows being used by service users were thinning and lumpy in some cases and would need to be replaced in the near future; this also applies to the towels and linen for all of the homes. The home provides care for service users who have a physical disability, it is acknowledged that the physical layout of the home does not lend itself to the provision of care for service users with wheelchairs, the corridors are narrow, there is little space for turning and there are limited adaptations. The home does have laundry cleaning schedules, however when staff were asked about infection control practices they were unable to give clear answers about how they would reduce the risk of cross infection to service users. When viewing the laundry, (85) it was noted that mops were not being stored inverted, there was no cleaning schedule for daily disinfection of mop heads and there were no disposable gloves or yellow bags for the removal of waste products. It was also noted that the plaster and paint in the laundry 85, was cracked and peeling, this must be repaired. The home has recently had a food premises inspection report completed; there are outstanding requirements within the body of that report which must be addressed to ensure the home complies with legislation. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can generally be assured that staff will be recruited in a safe manner and that they will be involved in the process. Staff do have training but there is evidence to suggest that not all them have understood the training they have received. There is sufficient staff on duty to meet the basic needs of service users. EVIDENCE: Staff files were examined to ensure that the home is continuing to improve its recruitment and selection of staff. New workers are recruited through the head office this means that information is passed onto the home via them. In some cases this meant that information was missing from individual files. For instance two of the new workers files examined had no confirmation of a PoVAfirst check or of a CRB disclosure, these were produced once the inspector had asked for them. In other cases there was an application form with no employment history contained within it, one member of staff had transferred to the home from children’s service, there was no evidence to suggest that home had taken steps to make the required PoVA and CRB checks for this worker. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 22 New workers had commenced employment with only a PoVAfirst check in place, this means that until their CRB disclosure is obtained workers must be appropriately supervised whilst they work but there was no evidence to suggest that this was the case. The manager did state that there is always a senior on duty but there was no identified person to take on this role on the staff rota. In addition to this the home does have a detailed induction programme for staff to undertake however this had not been completed in some cases. Staff who were spoken to did indicate that they had received training when they first began work and they felt supported whilst carrying out their duties. The staff rota did not provide an accurate picture of the activities of staff, for instance one worker informed the inspector that they had been asked to work at another home when it became understaffed, the staff rota had not been amended to reflect this. Staffing levels were also reviewed and it was noted that at times there seems to be too few staff on duty to assist service users when they need it. The manager stated that they are providing enough staff to meet the basic needs of the service users, when they request funding for extra staff to take service users out they can be refused. This means that during the week service users go out to day centres and shopping but at the weekend there is limited provision for them to go out and socialise. The home does not provide the services of a driver at the weekend. Staff spoken to during the inspection stated that they were given the opportunity through supervision to discuss their training needs and were given the opportunity to talk about aspects of their role that they found difficult to cope with, the manager keeps good records of this and as a result each member of staff has their own individual training and development file. It was pleasing to see that the manager arranges training for all of the staff and can easily identify when staff require refresher training to keep their knowledge and skills updated. This is important as some of the staff spoken to were unable to recall the contents of some of their training, in particular infection control and safeguarding adults. The manager continues to support staff as they undertake their NVQ level 2 training; the home is making progress with the number of staff that have this qualification. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is improving systems and practice but there are still improvements to be made. The quality assurance systems need to be reviewed to ensure that service users can participate in this process and the home can be assured that it is acting in service users best interest. The home is generally well maintained although record keeping and staff training could be further improved to ensure that the home is protecting the health and welfare of service users EVIDENCE: There has been no change in manager since the last inspection. Mrs Christine Till in registered with the Commission for Social Care Inspection and considered fit to run the home. Mrs Till is working hard to improve practice Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 24 and to raise the profile of the home. Since she began working at Alphonsus House staff have stated that there have been improvements, “Chris works hard to get us on training, you know the mandatory stuff”, “if I ever have a problem I will go to her”, service users stated “she’s taking me out for Christmas”, “we go out with Chris to the pub sometimes”. Quality assurance systems in the home have improved since the last inspection, this was pleasing to see. There are audits that address the environment, infection control and medication and more recently health and safety. What needs to happen now is for all of the issues raised during these audits to be put into an action plan so that the home can show how it is going to make improvements to its service. Further improvements are needed for the home to feel confident that they are finding out the views of their service users. For instance the home must be able to demonstrate how it has taken steps to involve all of the service users in this review process. It is not productive for the home to provide written questionnaires if the majority of service users cannot complete them. Policies and procedures must be reviewed and their relevance to the service assessed, for example to provision of policies that refer to older people and their care. The manager has systems in place that identify when mandatory staff training is due. As a result staff receive training and their knowledge should be updated. As mentioned previously it was evident that although staff had received required training during conversation it was apparent that they had forgotten or were unsure of some of the content, this means that there are gaps in knowledge that the manager should identify and address to make sure that service users are cared for by staff with knowledge of current good practice. Maintenance records for the home were spot checked and found to be in order. There must be an improvement in the recording of fire fighting equipment and fire safety checks such as emergency lighting and smoke detectors. It was noted that the basement under house 83 is filled with equipment, it is dusty and there are combustibles located within it. It was not clear when looking at the fire records if the smoke detector in this room was working this must be addressed promptly to reduce the potential risks to service users. Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 2 32 2 33 1 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 2 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 2 3 X 2 2 X 2 X Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 26 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1)(a) Requirement The registered person must ensure that sufficient staff are trained to the level of skills required to assess the needs of this client group and maintain current good practice – not met. Requirement originally made June 2006. Timescale for action 01/02/07 2. YA6 3 4 YA9 YA13 Care plans must be completed for all identified needs that contain sufficient information, including aims and goals. 13(4) Risk assessments must be completed for all identified needs. 16(2)(m)(n) Service users must be given the opportunity to participate in a range of community-based activities of a weekend. The home must arrange for all service users to have an annual holiday or the equivalent in daytrips, with records maintained indicating reasons why choices made. The home must be able to demonstrate that service users are offered a choice of meals DS0000004837.V322831.R01.S.doc 15(1) 01/02/07 01/02/07 01/02/07 5 YA17 16(2)(i) 01/02/07 Alphonsus House Version 5.2 Page 27 6 YA18 12(4)(a) 7 YA20 13(2) 8 YA21 23 9 YA23 13(6) 10 YA23 13(6) each day, with records maintained. Detailed records must be maintained for any service user who requires hourly checks through the night, demonstrating this only occurs if in the best interest of the service user. The policy and procedures document for the safe handling of medicines must be updated and amended to include the procedures identified as being absent. The secondary dispensing procedure also must be amended to comply with current practices and staff must be made aware of when it is acceptable to be used. The policy an ageing and illness which advocated staff discussing the benefits of will making with service users must be reviewed – not met. Requirement originally made March 2006. An audit of monies paid to service users must be undertaken in relation on monies agreed to be paid in an adult protection investigation. Any remaining monies owned must be paid directly in to service users accounts (including the service user who has now left the home). Service users inventories of personal belongings must be reviewed to include a record of items destroyed or removed from the premises and reasons why. Items that belong to the home must not be recorded on service users inventories. To provide the Commission for Social Care Inspection with a DS0000004837.V322831.R01.S.doc 01/02/07 01/03/07 01/02/07 01/01/07 01/01/07 11 YA24 23(2)(a)(c) 01/02/07 Alphonsus House Version 5.2 Page 28 12 YA30 13(3) detailed and comprehensive action plan to include timescales for action for repair of all damage to doors, door frames and walls caused by wheelchairs – not met. Requirement originally made March 2006. The manager must ensure that risks of cross infection are minimised Clean linen must be moved from the laundry without delay 01/01/07 13 YA30 13(3) Soap and paper towels for hand washing must be available at all times in the laundry for staff use (85) – not met. Requirement originally made January 2006. 01/02/07 The registered manager must ensure that there are disposable gloves and yellow bags available at all times for staff to use in the laundry (85) There must be a cleaning schedule that includes the disinfecting of mop heads on a daily basis. Staff must receive infection control training All staff must hold a national vocational qualification or be working towards one. The registered manager must ensure that staff have adequate rest periods between shifts. That staff do not exceed the 69 hours a week working hours indicated in the homes own risk assessment. Staffing must be calculated using a recognised staffing tool, based upon the assessed 14 15 YA32 YA33 18 18 01/03/07 01/02/07 Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 29 16 YA33 18 dependency levels of each service user. The hours must be compared to the hour’s provided/budgeted for. The outcome must be provided in writing to the CSCI with an action plan to meet any discrepancy identified between the two figures – part met. Requirement originally made January 2006. The numbers of staff must on 01/02/07 duty must sufficient to meet the individual and collective needs of service users. This must include the provision of a driver for service user at the weekend to enable them to go out. Staffing levels must be kept under review to reflect the changing needs of the service users. The duty rota must reflect accurately the numbers of staff on duty and their whereabouts at all times. Recruitment documentation must be available for all staff – part met. Requirement originally made October 2005. There must be a PoVA check for the care worker who currently only has a PoCA check All application forms must contain an employment history. 17 YA34 19 01/02/07 18 YA34 19 01/02/07 19 YA34 19 A recent photograph The registered manager must ensure that all staff who are recruited and permitted to commence employment with only a PoVAfirst check in place DS0000004837.V322831.R01.S.doc 01/02/07 Alphonsus House Version 5.2 Page 30 must: Appoint a member of appropriately qualified staff to supervise the new worker pending receipt of a CRB Ensure that the new worker is on duty at the same time as the supervisor The new worker must not escort service users away from the premises unless accompanied by a staff member To provide accredited staff training in accordance with policy (when developed) in relation to behaviour support and physical intervention –part met. Requirement originally made October 2005. All staff must receive equal opportunities training To ensure all staff receive an annual appraisal. To ensure that all staff receive at least six recorded supervision sessions per annum – part met. Requirement originally made June 2004. The registered manager must further develop the quality assurance system to include feedback from stakeholders in the community. Service users must complete their questionnaire with independent advocates. The manager must develop ways of involving all service users in the quality review process The provider shall formulate an appropriate system for reviewing at appropriate intervals and Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 31 20 YA35 18 01/02/07 21 22 23 YA35 YA36 YA36 18 18(1)(a) 18(1)(a) 01/03/07 01/03/07 01/03/07 24 YA39 24 01/03/07 improving the quality of care at the care home based upon consultation with service users and their representatives. There must be an action plan published once the results of the service users surveys are completed. To ensure that all policies and procedures are individualized to meet the needs of Alphonsus House. All policies, procedures and codes of practice etc, must be signed by the manager and dated – part met. Requirement originally made September 2006. To develop policies and guidelines for staff regarding pressure area care, ageing and death, adult protection and medication. To obtain and hold information and documents in respect of persons carrying on, managing or working at a care home listed in Schedule 2 and 4 of the Care home Regulations – part met. Requirement originally made January 2006. To ensure all staff receive training with regard to COSHH. – Not met. Requirement originally made June 2004. The registered manager must ensure that all fire safety checks are up to date and include the smoke detector in the basement of house 83. The registered manager must ensure that all staff receive training in first aid 25 YA40 18(1)(a) 01/03/07 26 YA40 12(1)(a) 01/03/07 27 YA41 17(2) Sch 2 01/02/07 28 YA42 18(1) 13(3) 01/03/07 29 YA42 13(3) 01/02/07 30 YA42 18(1) 01/03/07 Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 32 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 9 10 11 Refer to Standard YA6 YA6 YA6 YA6 YA7 YA20 YA22 Good Practice Recommendations That staff receive further guidance relating to the compilation of key worker meetings in order that they read as an overview of events from each month That person centred planning is implemented. That staff receive training in person centred planning. That an audit of service users files be undertaken with any items that are no longer relevant or out of date being archived. That a record be maintained of reasons why choices/requests by service users are not actioned. That service users be reassessed in relation to selfmedicating. That an audit of policies and procedures relating to complaints and protection be undertaken with old policies archived. That further work is undertaken to support service users to raise issues and/or concerns. That a monitoring system be introduced for adult protection. It is recommended to ensure that radiator covers allow for easy access to thermostatic controls valves The manager should obtain staff signatures to evidence that staff have received a copy of the General Social Care Councils’ Code of Conduct. Evidence should be retained on individual staff member’s personal files. To remove reference to marital status and dependents from the employee application form to ensure compliance with equal opportunities legislation. YA22 YA23 YA29 YA31 12 YA38 Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alphonsus House DS0000004837.V322831.R01.S.doc Version 5.2 Page 34 - 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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