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Inspection on 16/06/06 for Alphonsus House

Also see our care home review for Alphonsus House for more information

This inspection was carried out on 16th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 35 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff group were pleasant and were seen to be chatting with service users throughout the day. The grounds are well maintained and the internal environment was free from odour and provided a relaxing atmosphere for all service users. Service users meetings are being held on a regular basis and the manager is now writing an action plan following each meeting to demonstrate how service users needs and wishes are to be addressed. Service users are encouraged to take part in activities outside the home and maintain contact with their families.

What has improved since the last inspection?

Since the last inspection there has been progress in meeting previous requirements although not all are met, work to meet them is ongoing. The home has reviewed and amended the sources of information it provides about the home and made this available in picture format and can provide these in large print. Written confirmation is provided that assessed needs can be met by the home and a contract is provided on admission. Care planning has been reviewed and expanded to include long and short term goals and some plans are offered in picture format suitable to service users needs. Staff have broadened the range of risk assessments undertaken and undertaken further training.The home has developed some pictorial aids for the menu`s. The patio area outside house 81 that was uneven is now level and means that service users are able to sit out in the garden and the risk of tripping has been reduced. It was also pleasing to see that staff training has improved and regular training sessions have been carried out equipping staff with the knowledge and skills to be able to care for service users safely. The home now has a quality assurance system in place, which demonstrates the homes commitment to developing the service in the best interests of the service users. The staff rota now reflects a true picture of the staff on duty during the day.

What the care home could do better:

The assessment process would benefit from more staff being developed through training which has the added benefit of maintaining the process in line with current good practices. Good care planning is liable to be undermined if monitoring records are not completed accurately and up to date. Equipment used to assist in the delivery of care must be risk assessed and consent received for its use. Improvements have been made in the recruitment and selection of staff but the manager must ensure that all required documentation for each staff member is available at the home at all times. It was evidenced during the inspection that some staff are working in excess of 69 hours a week and others are working without sufficient time to rest between shifts. The manager must address this to ensure that staff are adequately rested and service users are not placed at risk by tired and exhausted staff.

CARE HOME ADULTS 18-65 Alphonsus House 81 - 85 Vicarage Road Oldbury West Midlands B71 1AH Lead Inspector Mandy Beck Key Unannounced Inspection 16th June 2006 09:30 Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 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.V294554.R01.S.doc Version 5.1 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.V294554.R01.S.doc Version 5.1 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 (No. 2) Limited Mrs Christine Ann Priscilla Till Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 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. One service user identified in the variation report dated 17 August 2005 may be accommodated at the home in the category SI. This will remain until such time that the identified service users placement is terminated at which time the category will revert back to LD only. 24th January 2006 2. 3. Date of last inspection 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 £320 to £1348 for each week. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by two inspectors from the Commission for Social Care Inspection it took ten hours to complete and was the first of the homes two inspections this year. A range of methods was used to gain information and knowledge of the service. This included talking with the manager, service users and staff throughout the day. Service user and staff files were seen in order to make judgements about the homes progress in meeting the National Minimum Standards and a tour of the premises was also included. All of the key standards were assessed during this inspection. The inspectors would like to thank all of the service users and staff for their hospitality throughout the inspection. What the service does well: What has improved since the last inspection? Since the last inspection there has been progress in meeting previous requirements although not all are met, work to meet them is ongoing. The home has reviewed and amended the sources of information it provides about the home and made this available in picture format and can provide these in large print. Written confirmation is provided that assessed needs can be met by the home and a contract is provided on admission. Care planning has been reviewed and expanded to include long and short term goals and some plans are offered in picture format suitable to service users needs. Staff have broadened the range of risk assessments undertaken and undertaken further training. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 6 The home has developed some pictorial aids for the menu’s. The patio area outside house 81 that was uneven is now level and means that service users are able to sit out in the garden and the risk of tripping has been reduced. It was also pleasing to see that staff training has improved and regular training sessions have been carried out equipping staff with the knowledge and skills to be able to care for service users safely. The home now has a quality assurance system in place, which demonstrates the homes commitment to developing the service in the best interests of the service users. The staff rota now reflects a true picture of the staff on duty during the day. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 7 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.V294554.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 The overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and prospective clients are provided with good sources of information about the home and are invited to spend time at the home prior to admission to enable them to make an informed decision about entering the home. The staff group are stable, well established and collectively have the knowledge and skills to assess needs and to meet the assessed needs of the current service users. Each service user has a individual written contract for their occupancy of a place at the home EVIDENCE: The Statement of Purpose and Service Users Guide (information file) have been subject to review and provide a good source of information about life at the home in written and pictorial formats. Two service users files were selected for inspection of the assessment process with a further two used to examine the assessment of specific needs. Experienced staff of the home undertake an extensive range of assessments including pre-admission assessment of prospective service users using an Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 9 activities of daily living, outcomes based approach, the number of staff with the skills to undertake assessments of this client group needs to be extended if the home is to demonstrate it is based on current good practice and that they keep up to date by continuous learning. A letter is provided that confirms that the home will be suitable to meet the assessed needs and a copy is maintained on file. Pre-admission visits and an extended trial period is considered essential in establishing that the prospective service user will settle into the home and be accepted by other service users. In addition to the homes needs assessment and covering items identified in standard 2.3 for adults the Care Management Assessment/Care Plan (single assessment process) is also on file. A range of risk assessments are undertaken as required by the standards and on an individual needs basis such as travel, swimming classes, nutrition and pressure relief needs. All assessments are subject to regular reviews and evidence was seen of seeking advanced practitioners advice for the contingency arrangements for dealing with conditions such as diabetes and epilepsy. The assessment process also identified required aids and adaptations, social and educational activities involved and extensively sought personal likes and dislikes. Each of the files included a copy of a social services contract. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning at the home is good, clear and consistent, providing staff with the necessary directions of actions required but omissions in monitoring may result in service users care needs not being fully met. Service users are fully involved in all aspects of life at the home and are supported to make decisions for themselves and encouraged to maximise their independence to achieve an individual life style. EVIDENCE: The same sample of case files were used for case tracking, these include the most recent admission, a service user with additional general health problems and one long established service user. Each case file was found to contain care plans that were drawn up to address assessed needs and problems and these were kept under frequent review. The inspector found the language used and pictorial versions in the documents to be user friendly with plenty of evidence of service user involvement in all aspects of assessment, care planning and reviews. Monitoring charts in support of the care plans were Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 11 available, some examples were viewed of omissions in keeping the record such as a bowel chart that recorded some movements but no indication given that blanks were because of no movement or not observed and suggested the record was of little value. The plan identifies special requirements for such conditions as diabetic hypo and hyper glycaemia and delayed recovery following epileptic fits. Individual procedures are developed for service users who may present with behavioural challenges and these appear to be focussed positively and preventative. Where there is a need to restrict freedom, such as leaving the home alone this is arrived at with the agreement of the service user. The case file shows the involvement of the service user and social worker in the development and review of the care plans. Records of GP and Consultant visits are maintained. None of the current service users manage their own finances but individually are supported to handle cash for purchases. One service user who is waiting for a welfare assessment receives financial support from the company to ensure a personal allowance is available to meet day to day needs. Each service user case file includes a range of risk assessments to enable service users to take up activities of their choice with an action plan to minimise risk and identify training need within individual capacity to learn. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are individually assisted to pursue personal development and leisure activities. The involvement of family and friends is encouraged in agreement with the service users wishes. The home provides a varied social and recreational activity programme that provides interest and pleasure for service users. Meals at the home are wholesome and meet the nutritional needs of service users while providing for choice and personal taste. EVIDENCE: Of the service users case tracked one was noted to continue full time education at college, which commenced prior to entering the home and is developing employment skills. Each service user has an individual activity plan and daily routine plan with records maintained of their implementation. It was observed that individual routines were flexibly undertaken to allow the service users to Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 13 choices of the moment. Service users are assisted in obtaining benefits and making choices on expenditure on personal items such as clothing, music and film, beauty products. The range of activities is extensive with service users individually accessing them as they are able such as trips into the community to take up swimming, shopping, attending day centres, going to the cinema and having meals out. Service users were observed to be exercising choice in participating in activities and choosing to be alone in their own room and demonstrating their independence, by maintaining their own rooms as they were able. The home was observed to provide unrestricted access within the home and garden areas and service users were seen to move about the different parts of the home. The case files now show the involvement of family and how this is usually taken up by them whether involvement in the home or trips out or participating in events at the home. There is a four-week rotational menu in operation, which includes choice at the three main meals; supper is included on the menu. Lunch was served during the inspection the meal looked appetising and nutritious and enjoyed by all. In conversation with service users they were able to communicate their view that the meals were good. Staff described how the service user who was at college prepares his own packed lunch each day and others were observed to take their lunch outside of the routine time to fit in with their individual wishes and activity. Service users nutritional needs are assessed and monitoring of weight is undertaken routinely. A service user with diabetes has a plan to address hypo and hyperglycaemia and advice taken from a specialist nurse. Menus feature prominently in the service users meetings and opportunity is made to include personal preferences which creates a varied and interesting selection of meals. Fresh fruit and vegetables are available daily. Service users are involved and assist with the shopping at the local shops and supermarkets. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assisted to maximise their independence and control over their lives and staff respect their privacy and dignity and give personal support to achieve this. Healthcare needs are well documented and are compiled with the input of the individual service user. The care plans give clear directions to ensure that service users’ healthcare needs are assessed, recognised and addressed. EVIDENCE: Each service user has an individual plan that identifies personal support needs and preferences in how activities of daily living are undertaken and applied flexibly allowing independence and free choice. Service users were seen to make choices about clothing, how they do their hair on any particular day and among the ladies whether to wear make up. The service users files used for case tracking evidenced that personal support assistance is given such that independence is promoted. Good histories are documented that identify likes and dislikes which assists in the delivery of care for those who are unable to easily communicate their wishes. The files also show the involvement of families, advocates and professionals. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 15 All service users have their health needs met and the care plans evidence general practitioner and other health care professionals input. Evidence was seen of service users attending appointments and receiving specialist health professional inputs. Conditions such as epilepsy and diabetes are monitored and guidance provided to deal with complications that may arise. The medication practices within the home were not assessed on this occasion, the home is awaiting an unannounced inspection from the CSCI pharmacy inspector who will monitor the progress they have made in meeting the outstanding requirements. This is reflected in the requirements section where it states to be assessed by the pharmacy inspector. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Service users do feel that their views are listened to and acted upon. There are policies in the home that protect service users from harm however all staff must be trained to recognise abuse, neglect and self harm to ensure that service users are in safe hands all of the time. EVIDENCE: The home has a detailed complaints policy and procedure, service users spoken to indicated that they felt confident in talking to the manager and staff if they felt unhappy about any aspect of their lives whilst living at Alphonsus House. The home has received no complaints since the previous inspection in January 2006. There was evidence that some staff have now received training in adult abuse awareness a further training session has been planned to include those staff who have not completed this training. The home’s policy has not been reviewed to reflect current good practice. The manager did state that all of the relevant information was available to staff, both national and local guidance was available for staff and service users. Some staff have received training in “behaviour that challenges” more staff are expected to complete this soon. The knowledge from this training will give staff the skills to be able to understand and deal with behaviour they find challenging. Service users monies were also looked at. The home manages personal allowance for all of the service users, none of the current service user group handle their own finances. Monies were kept securely and are audited Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 17 regularly, those monies seen during inspection were correct and demonstrated each withdrawal and deposit. Receipts were available for all transactions. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Service users live in homely comfortable environment. Generally the home is clean and free from offensive odour. EVIDENCE: A tour of the premises was undertaken and it was pleasing to see that some of the previous requirements had been addressed. The patio area was even and safe for service users to use and the décor damaged by fitting new windows had been made good. The damage to the doors and walls caused by the wheelchairs had not been addressed and still requires attention. There had been a leak in the bathroom in house 83 that had caused damage to the ceiling that needs to be addressed. There have been improvements to the décor and the appointment of a new maintenance worker means that some of the other outstanding maintenance issues are being addressed. Both laundry’s were seen and it was pleasing to see that both had been decorated recently and that the peeling paint was no longer visible. Clothing is now being sorted by staff and there was evidence of gloves and aprons to help reduce the risk of cross infection. Disappointingly there was no soap or paper Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 19 towels in the laundry under house 85 this means that staff still cannot wash their hands effectively after handling laundry. Mops were clean but must be stored inverted to further reduce the risk of infection. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Staff are generally recruited in a safe manner and staff training has improved to enable service users to have their needs met by suitably qualified staff. EVIDENCE: At present there are a total of 5 staff who have completed their NVQ level 2 with a further 8 staff working towards theirs. This does not meet the National anticipated that the remaining 8 staff will have completed their NVQ level 2 by the end of the year. Staff training has improved and it was pleasing to see that on the day of the inspection staff were involved in health and safety training. Other training that has taken place recently includes, nutrition, diabetes awareness and an introduction to Makaton. Recruitment processes within the home were generally satisfactory although there are still some improvements required. All staff files should contain all the required information but some of the files seen had incomplete applications forms, this makes checking employment histories for employees difficult. Other files did not contain job descriptions or terms and conditions of employment. The manager stated that this is because information goes to head office and comes back to the home a bit at a time. The manager and head office must consider ways to ensure that all of the documentation arrives at the same time to ensure that information is available. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 21 It was pleasing to see that in exceptional circumstances staff are employed on a PoVA first check only but the risk assessments had been completed and the member of staff was being supervised whilst on duty and was not permitted to carry out personal care. All of the staff on duty were aware of this and all stated that the worker never works alone. The organisation has a training coordinator who is responsible for arranging all the training required by the home. Craegmoor healthcare have developed their own induction and foundation programme for new starters and this has been done in conjunction with the Learning Disability Award Framework (LDAF) to provide staff with the underpinning knowledge they will need to work in the home. Each member of staff has their own individual training folder, which details their training achievements and certificates. Whilst other standards were not looked at in depth during this inspection the staff rota was checked. It was observed that on this particular day it was a true reflection of the staff on duty. However more concerning was the fact that staff are working in excess of 69 hours a week in some cases and others are not having enough rest time between shifts. The manager must address this to ensure that service users are not placed at risk by staff who are too tired to complete their duty due to working excessive hours. The home has risk assessments in place to manage staff working up to 69 hours in one week but not for the hours in excess of 69. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Service users can feel confident that their views will be taken seriously and that the welfare of both staff and service users is promoted. EVIDENCE: Since the last inspection the manager has now been registered with the Commission for Social Care Inspection. She is both qualified and competent to run the home. There have been great improvements in the quality assurance systems the home has in place since the last inspection. The manager has conducted an audit of service users views, unfortunately not all the service users were able to participate in this process and the manager needs to consider ways of making this possible for the next audit. In addition to this the manager has completed audits on the home, medication and the environment. In order to build upon this work the manager now needs to collate all of this information and formulate an action plan that will demonstrate how those findings can be acted up for the benefit of the service users. This will also demonstrate the home’s commitment to improving the service they provide. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 23 The homes safe working practice is generally well managed although some of the records seen had not been completed since February 2006. the manager stated that this was because the new maintenance worker was unaware that recording should be documented. This was concerning because the records not being maintained were those relating to fire alarms and emergency lighting. As mentioned previously training in fire safety, first aid, health and safety and moving and handling had all recently taken place within the home. Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 2 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x X 3 X 2 X X 2 X Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA3 Regulation 14(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. The registered person must ensure that monitoring records in support of care plans are completed fully and up to date. Documented consents must be filed for the use of items of equipment such as bed rails. Staff who are witnessing the administration of medication must be appropriately trained NEW REQUIREMENT AT MAY 05 Not assessed at this inspection, to be assessed by the pharmacy inspector Medication profiles in care plans must be updated to include nutritional supplements where prescribed NEW REQUIREMENT AT MAY 05 Timescale for action 30/09/06 2 YA6 15(1) 30/09/06 3 YA20 13(2) 30/09/06 4 YA20 13(2) 30/09/06 Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 26 5 YA20 13(2) Not assessed at this inspection, to be assessed by the pharmacy inspector The medication PRN guidelines (including lorazepam) must be reviewed to ensure the accuracy of the information held and to ensure the accurate administration of “as required” medication. The circumstances for the administration of “as required” medication must be specific and as per medical advice Not assessed at this inspection, to be assessed by the pharmacy inspector. The ensure care plans contain guidelines of when individual residents’ PRN, (as required) treatment is to be administered and the frequency 30/09/06 6 YA20 13(2) 30/09/06 7 YA20 13(2) Not assessed at this inspection to be assessed by the pharmacy inspector. To provide the Commission for 30/09/06 Social Care Inspection with a detailed and comprehensive action plan to include timescales for action for the following area: Establishment of a written protocol for staff regarding action required if medication stock is exhausted. Not assessed at this inspection, to be assessed by the pharmacy inspector 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 DS0000004837.V294554.R01.S.doc 8 YA20 13(2) 30/09/06 Alphonsus House Version 5.1 Page 27 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. To be reassessed by the pharmacy inspector The homes’ MDS system must not be released to residents when they wish to stay away from the home. The home must either make arrangements with the Pharmacy to have the required medication packed into alternative containers or if very little warning is given by the resident, instigate the new and improved secondary dispensing procedure. Immediate requirement made by CSCI pharmacy inspector August 5th 2005 To be reassessed by the pharmacy inspector 30/09/06 When residents wish to stay away from the home an accurate record must be made of the medication released to them and returned to the home so that compliance to take the medication whilst away from the home can be monitored Immediate requirement made by CSCI Pharmacy Inspector August 5th 2005 To be reassessed by Pharmacy Inspector The home must ensure that 30/09/06 every possibility is explored to make sure that the residents’ medical conditions, that require continuous treatment are treated continuously. DS0000004837.V294554.R01.S.doc Version 5.1 Page 28 9 YA20 13(2) 30/09/06 10 YA20 13(2) 11 YA20 13(2) Alphonsus House Immediate requirement made by CSCI Pharmacy Inspector August 5th 2005 To be reassessed by Pharmacy Inspector. The home must investigate why the resident’s MAR chart had been signed for the administration of a Trazadone capsule when the capsule had not been administered. Requirement made by the pharmacy inspector August 5th 2005 To be reassessed by the pharmacy inspector The home must obtain a clear written protocol for the administration of “when required” medication from the resident’s GP describing at what point the medication may be administered. Requirement made by the CSCI pharmacy inspector August 5th 2005 To be reassessed by the pharmacy inspector A maximum/minimum thermometer must be obtained and used to record the maximum and minimum temperatures of the fridge on a daily basis. Requirement made by the CSCI pharmacy inspector August 5th 2005 To be reassessed by pharmacy inspector The home must ensure that staff responsible for the DS0000004837.V294554.R01.S.doc 12 YA20 13(2) 30/09/06 13 YA20 13(2) 30/09/06 14 YA20 13(2) 30/09/06 15 YA20 13(2) 30/09/06 Alphonsus House Version 5.1 Page 29 administration of residents medication undertake and complete an accredited medication handling course. Requirement made by the CSCI pharmacy inspector August 5th 2005 To be reassessed by the pharmacy inspector The policy an ageing and illness which advocated staff discussing the benefits of will making with service users must be reviewed Previous timescale of 31/03/06 not met The adult protection policy must be reviewed in line with National and Local guidelines. The reviewed policy must be dated and signed. All staff must be provided with training in Adult Protection (previous timescale 31/03/06 not met) That the provider assess the 30/09/06 extent of the financial losses incurred to all service users through the practice of staff using service users money to meet their out of pocket expenses when supporting service users to access the local community and holidays (from the time that Craegmoor became the provider at Alphonsus House) That the provide proposes to all service users and their representatives how they intend to make good financial losses to all service users incurred, with a copy of all proposals to the Commission for Social Care DS0000004837.V294554.R01.S.doc Version 5.1 Page 30 16 YA21 23 30/09/06 17 YA23 13(6) 30/09/06 18 YA23 13(6) Alphonsus House Inspection. These requirements made November 2005 Proposal received on December 15 2005 – at January 2006 action required Not assessed at this inspection 23(2)(a)(c) To provide the Commission for Social Care Inspection with a detailed and comprehensive action plan to include timescales for action for repair of all damage to doors, door frames and walls caused by wheelchairs (previous timescale 31/03/06 not met) 13(3) The manager must ensure that risks of cross infection are minimised Clean linen must be moved from the laundry without delay Soap and paper towels for hand washing must be available at all times in the laundry for staff use (85) (previous timescale of January 2006 not met) 50 of care staff must achieve NVQ level 2 in care by 2005 (previous timescale of 31/03/06 not met) 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 Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 31 18 YA24 30/09/06 19 YA30 30/09/06 20 YA32 18 30/09/06 21 YA33 18 30/07/06 upon the assessed dependency levels of each service user. The hours must be compared to the hours 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. Immediate requirement at MAY 2005, not met. Not reassessed at January 2006 (previous timescale not met 28/02/06) To ensure Medication Records are available at all times – to be assessed by the pharmacy inspector. To ensure that all records required by Regulation 17 are maintained, are at all times available for inspection and retained for not less than three years from the date of the last entry. To provide documentary evidence to the CSCI that actions 1 –6 have been met and a protocol to ensure that these requirements will continue to be met. Legal notice issued December 8 2005. Not met Not assessed at this inspection The personal file for PE must be updated to include all required information Recruitment documentation must be available for all staff (previous timescale of DS0000004837.V294554.R01.S.doc 22 YA33 17 30/09/06 23 24 YA34 YA34 19 19 30/09/06 30/09/06 Alphonsus House Version 5.1 Page 32 21/10/05 not met) 25 YA35 18 To provide accredited staff training in accordance with policy (when developed) in relation to behaviour support and physical intervention (previous timescale of 21/10/05 not met) To ensure all staff receive an annual appraisal 30/09/06 26 27 YA36 YA36 18(1)(a) 18(1)(a) 30/06/06 To ensure that all staff receive at 01/01/07 least six recorded supervision sessions per annum (previous timescale of June 2004 not met) The registered manager must further develop the quality assurance system to include feedback from stakeholder 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 improving the quality of care at the care home based upon consultation with service users and their representatives. 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 Not assessed at this inspection DS0000004837.V294554.R01.S.doc 28 YA39 24 30/09/06 29 YA40 18(1)(a) 30/09/06 Alphonsus House Version 5.1 Page 33 30 YA40 12(1)(a) To develop policies and guidelines for staff regarding pressure area care, ageing and death, adult protection and medication Not assessed at this inspection 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 (previous timescale of 31/01/06 not met) A letter from the Environmental Health Department confirming that all of the recommendations/requirements in their report dated 24 November 2004 must be forwarded to the CSCI To ensure all staff receive training with regard to infection control and COSHH. 30/09/06 31 YA41 17(2) Sch 2 30/09/06 32 YA42 13 30/09/06 33 YA42 18(1)(c) 13 (3) 30/09/06 34 YA43 25(1) (c ) (previous timescale of June 2004 not met) The home must provide a 30/09/06 business and financial plan which should be held on the premises and available for inspection. Plan not available at January 2006. Not assessed at this inspection Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 34 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 Refer to Standard YA20 Good Practice Recommendations To ensure that staff responsible for administration of medication sign and date the medication administration policy to confirm that they have read and will agree to administration procedures, including the registered manager The medication policy makes references to some corporate procedures (such as action to be taken in the event of drug errors). It is recommended that a copy of the corporate procedures referred to are held together with the home’s individual medication policy. It is recommended that all staff receive training in the monitored dosage system as are staff who may be witnessing the administration have not received training in the safe handling of medication. It is recommended that the positioning of the procedures within the safe handling of medicines document be changed to make it more user friendly. It is also recommended that the two administration procedures found within the document are combined and the Homely Remedies protocol is amended as per text above. It is recommended that the positioning of the cabinet be reviewed taking into account the difficulty of removing the residents medication at floor level Recommendation originally made August 2005 It is recommended that staff are made aware of the information that should be recorded in the Controlled Drugs register and consistently enter this information Recommendation originally made August 2005 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 members personal files. To remove reference to marital status and dependents from the employee application form to ensure compliance with equal opportunities legislation. 2 YA20 3 YA20 4 YA20 5 YA20 6 7 YA29 YA31 8 YA38 Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 35 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alphonsus House DS0000004837.V294554.R01.S.doc Version 5.1 Page 36 - 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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