Inspection on 18/08/08 for Alphonsus House

This inspection was carried out on 18th August 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alphonsus House 22/08/07

Alphonsus House 12/12/06

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 08/11/2008.

CARE HOME ADULTS 18-65 Alphonsus House 81 - 85 Vicarage Road Oldbury West Midlands B71 1AH Lead Inspector Lesley Webb Key Unannounced Inspection 18th August 2008 08:00 Alphonsus House DS0000004837.V369892.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.V369892.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.V369892.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 alphonsus.house@craegmoor.co.uk for AQAA www.craegmoor. Co.uk Parkcare Homes Ltd 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) Clare Louise Booth Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Alphonsus House DS0000004837.V369892.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. 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. 22nd August 2007 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 16 single bedrooms situated on the first and ground floors. Access to the first floor is by stairs only there are no passenger lifts in this home. 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. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We carried out this inspection over one day, with the home being given no prior notice of the visit. Time was spent examining records, talking to residents, staff and observing care practices, before giving feed back on our findings to the registered manager. Prior to the inspection the home supplied information to the Commission for Social Care Inspection (CSCI) in the form of its Annual Quality Assurance Assessment (AQAA). Also twelve residents surveys were completed and returned to the CSCI. Information from both these sources was also used when forming judgements on the quality of service provided at the home. The people who live at this home have a variety of needs. We took this into consideration when case tracking three individuals care provided at the home. For example the people chosen consisted of both male and female and have differing communication and care needs. An Expert by Experience accompanied us during part of the inspection. This is someone who receives a service themselves and also has a disability. Their findings are also included in this report and used as evidence when deciding on the quality of service provided at the home. The atmosphere within the home is inviting and warm and we would like to thank everyone for his or her assistance and co-operation. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: Prospective new residents have their needs assessed before moving into the home. This means the home understands these before offering a placement to people. In one of the houses we saw staff sitting eating the evening meal with residents. Residents informed us the meal was very nice, the atmosphere was relaxed and people appeared to be enjoying selves. All residents that we met were appropriately dressed for their age, the weather and gender. This promotes their dignity. A resident we spoke to confirmed they are happy with the support they receive with regard to personal care explaining, “my nails are varnished and toe nails, they are lovely”. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 6 There are good arrangements for the ordering, receipt and safe storage of medication. This means residents medication is looked after safely by the home. The way the home looks after residents personal money is good and offers protection. In the main residents live in a safe and comfortable environment. The home continues to recruit people in ways that safeguard residents. Maintenance records show that repairs to the home are carried out so that building that people live in is safe. What has improved since the last inspection? Residents’ contracts and terms and conditions have been reviewed, and unfair terms and conditions are removed. Improvements with regard to residents having the opportunity to go on holiday have been made. The registered manager informed us that eleven of the residents are going on holiday this year, 2 to Great Yarmouth, 2 to Bournemouth, 3 to Minehead, 2 to Centre Parks and 2 with their families. Since the last inspection residents have been assessed as to whether they are able to self medicate. This is positive as it supports people to be independent. Craegmoor have now introduced a competency assessment for all staff that administer medication to ensure that they are safe practitioners and are not placing residents at risk with poor practice. The complaints procedure has been produced in pictorial format and is included in the service user guide. This helps residents to understand what to do if they are unhappy. There have been improvements to the home since our last visit. Most of the residents have had their bedrooms redecorated. A kitchen and office have also been decorated and the gardens tided and replanted. This is good investment by the company that owns this home and helps promote a comfortable and safe place for residents to live. Staff has undertaken a lot of training. This ensures they have the necessary knowledge to support people living at the home. There are currently no vacancies apart from 2 night shifts, which are covered by part time night workers. This improvement in the stability of the staff Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 7 group is a benefit to residents as it helps ensure they receive consistent support. Ms Claire Booth became the registered manger at Alphonsus House in June 2008 after commencing employment there in February 2008. She was present throughout our inspection and presented as committed to continuing to improve the quality of service people living at the home receive. She recognised work is still required and offered assurances that actions will be taken to address this. Residents meetings have been reinstated as another way of obtaining views of people. The majority of staff have undertaken basic food hygiene, fire safety, first aid, health and safety and manual handling training. This helps ensure residents’ safety is maintained. What they could do better: Health records of residents must be accurate and up to date to ensure people’s needs are met safely. A hoist must be used unless a suitably qualified person such as an Occupational Therapist assesses this is not in the best interests of a named resident. Referrals in line with local authority safeguarding procedures must be made for any unexplained injury to a resident. This will help protect them from harm. Staffing levels must be maintained when people take annual leave, maternity and sick leave. This will ensure residents’ needs are met by safe staffing levels. Work should continue to ensure specific care plans are implemented for all identified needs. Also work should be undertaken to evidence decision-making protocols undertaken when the decision is made that a person lacks capacity. The home must be able to evidence compliance with the Mental Capacity Act. This will help promote peoples rights. All residents should be supported to participate in activities both in and outside of the home. The home should discuss with residents what abuse is, the types of abuse that happens and what to do about it. This is so residents will not be afraid of reporting it and feel shy about talking about abuse. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 8 The home should contact the Health Protection Agency for advice with regards to the laundry and implement any recommendations made. This will promote good infection control within this facility. Access to each house should not be shared. This will promote a more personal feel and be more respectful to people living there when visitors arrive. Please refer to the back of this report for a full list of recommendations. 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.V369892.R01.S.doc Version 5.2 Page 9 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.V369892.R01.S.doc Version 5.2 Page 10 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): 2,4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective new residents have their needs assessed before moving into the home. This means the home understands these before offering a placement to people. Not all prospective residents have the opportunity to visit the home before moving in to help decide if it will be suitable for them. EVIDENCE: By looking at the records of the newest person to move into the home we found that pre-admission assessments identify needs of potential residents. The personal assessment for this person covers areas including health needs, eating and drinking, finances, mobility, routines, personal care, mental health, social interaction and leisure. The home uses a document titled ‘Every day care plan’. This is a form of assessment as it is from this specific care plans are generated for identified needs (this is discussed further in the care planning section of this report). In addition to the homes assessment a copy of the placing authorities care plan was on file for this person. We found no evidence that the resident had visited the home before moving in. We discussed this with the registered manager who confirmed this to be the case. We advised trial visits should take place not only so that the home can be confident of meeting new residents needs but in order that an Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 11 assessment of compatibility of others already living there is undertaken. The homes assessment documentation currently does not include for this to be recorded. The registered manager informed us that since the last inspection residents contracts and terms and conditions have been reviewed, and unfair terms and conditions are removed. She also informed us that these are still not available in different formats that would help residents understand them but that staff discuss them with residents. We advised that work continues to produce this in different formats so that people are fully involved in and are aware of their rights and responsiblities. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 12 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. Each resident has a care plan but the practice of involving residents in the development and review of these is variable. Efforts are being made to support residents to make decisions but further work is needed to evidence the views of residents are acted upon. Further improvements to care planning and risk management will promote person centred support. EVIDENCE: We looked at the care records for 3 residents and found that care plans have been generated from assessment documentation but further work is needed to ensure these are in place for all identified needs. For example one persons ‘Every Day Care Plan’ states they have a visual and hearing impairment but then states no care plan or risk assessment have been developed. The same persons plan states they are overweight due to thyroid problems but does not say how they are to be supported in this area. Another residents ‘Every Day Health and keeping Safe Plan’ states they are blind in one eye but no specific Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 13 care plan or risk assessment are in place that gives instructions to staff how to support the person in this area. This same document states there is no health action plan, the annual health check section is blank and that vaccination history is not known. We found a letter from this persons General Practitioner confirming they had received an annual health check and a copy of a health action plan on file. We discussed the inconsistencies with recordings with the registered manager, as the monthly reviews undertaken by staff have not identified these issues. Some of the care plans we looked at have been signed by residents to confirm their agreement of the contents and other have not. We discussed this with the registered manager, advising that if a resident is unable to be involved then advocates or family should do this. The Expert by Experience talked to residents and staff about care plans and also found inconsistencies with information. As they explained, “I asked if the persons communication was in a plan anywhere. Staff said it’s all in his care plan but it’s the main house because of the inspection. For the person’s communication details to be in his care plan I think it would be better to be kept separate, to have a plan just on communication needs- like a communication passport” and when talking to a resident, “I asked the person I spoke with if he had a care plan or any other types of plans about his life. I was very pleased to see him get up straight away, go into the kitchen and show me his PCCP. This plan had lots of good detail in it, including questions asking about what would happen if this person was seriously ill or died. I was really pleased to see so much detail, I hope it’s the same for everyone’s”. The inconsistencies in recordings were found on another residents file. Staff have recorded no changes to care plans when reviewed monthly when evidence indicates this is not so. For example the residents care plan for eating and drinking states they are very underweight and that they are to be given additional foods throughout the day. Records of meals do not show additional foods given. A member of staff informed us the resident is no longer underweight or on any supplements. The home completes a ‘Life Story’. This is a record that gives information about the person’s history. This had not been completed for the newest person to move into the home and was part completed for another resident. A resident with epilepsy was found to have a detailed and informative care plan for epilepsy. This means staff have the information needed to support the person in this area. A risk assessment is also in place. This is basic and only identifies environmental risks. A second resident had a detailed care plan for weight management but as with the first a basic risk assessment that does not identify all risks and control measures. The resident who is being supported to lose weight expressed their satisfaction with this, explaining, “lost a lot of weight, its good exercise going up and down stairs, I was 18 stone now 14, its great to be healthy”. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 14 Efforts are being made to involve residents in decision-making processes such as holding monthly one to one meetings with key workers and group meetings for residents. Not all records of meetings have been signed by the residents and the minutes of key worker meetings still read as statements of need and not a review of the persons needs for that month. For example one persons records state ‘staff to manage diabetes’ ‘goes out with sister, shopping and cinema’ and another ‘must have all medication at right time, staff to monitor seizure’. These are statements of need and not an overview of what has happened to the person that month. It is positive that residents meetings are divided into 3 groups reflecting the people they live with. Within these meetings topics are discussed such as activities, meals and staff. We discussed with the registered manager the need to evidence action taken to meet requests made by residents in these meetings, as records currently do not show this. For example the minutes of one meeting state ‘would like water feature, more plants in garden’ but the action recorded is ‘keep garden tidy’. Another record states ‘would like to go bowling, swimming, karaoke, pub and concert’. No record of action is in place for these requests. Records on 2 of the 3 residents files we viewed with regard to consenting to share personal information state the residents lack capacity to make this decision. We discussed this with the registered manager advising that work should be undertaken to evidence decision-making protocols undertaken when the decision is made that a person lacks capacity. The home must be able to evidence compliance with the Mental Capacity Act. This will help promote peoples rights. It was recommended at a previous inspection that staff should be given guidance on how to complete the new Person Centred Care Planning system to avoid misunderstandings occurring. At this inspection the registered manager informed us that some staff have received in-house training, and that Craegmoor are providing one days training in October and December. This was pleasing to hear as evidence sited above indicates this is needed in order that accurate and clear care planning documentation is maintained. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 15 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): 11,12,13,14,15,16 and 17. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all residents are supported to make choices about their life style or to develop their life skills. Social, educational, cultural and recreational activities do not meet individuals’ expectations. Meals meet individual needs. EVIDENCE: As at the previous inspection the home needs to concentrate on developing activities for those residents who cannot access the community as freely as others. This will give all residents equal opportunity to take part in activities. All 3 residents files that we examined contained activity plans. For one person (able bodied) this details working at a charity shop 2 times a week, relaxing in the house, puzzles, own choice of activities, shops, haircut, food shopping, TV, washing clothes and trip out. This persons records state they like football and when we viewed their bedroom we found it to contain an abundance of football Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 16 items. A member of staff informed us, “he’s a really big fan, loves football”. It was disappointing to find no evidence that this person has been given the opportunity to go and watch a football match. The activity plan for another resident (physically disabled) details listening to music, ride to shops, medical centre to have dressing changed and keep fit. As we explained to the registered manager a health appointment should not be classed as an activity as this is a responsibility of the home to ensure health needs are met. The daily records for this person for August 2008 detail activities as birthday party, listening to music, watching TV and DVD, in back garden, trip to safari park, took parents home and then shopping and ‘looking out of window’. We discussed this with the registered manager advising that looking out of a window should not be classed as an activity. This same person has a sensory plan completed by an Occupational Therapist that details activities that should be provided for stimulation. We could find no evidence of these being provided and the contents of the plan have not been reflected in the homes care plan when this was reviewed. The Expert by Experience met this resident and talked to staff about their life, also finding lack of stimulation. As they explained, “I asked what the person was doing today and staff said he doesn’t really do a lot, but will be going out in the minibus on Thursday, today is Monday. I asked what other things this person likes to do, staff said they are hoping to get him a new chair so he is able to get out of his wheelchair now and again. Staff said the person had the money but sometimes it’s hard to spend. I asked if the person accesses any sensory places, staff said in the 2 years she had worked there he had not but this was due to some behaviours this person had in the past when he accessed somewhere. I asked if staff had looked at any centres to access. Staff said day centres would not accept him due to having personal care needs and the home could not release staff to go with him during the day. I was horrified this person has barely anything to do with his life, he doesn’t seem to have any stimulation, no regular things he accesses. This made me really sad and angry. This person should be trying new things everyday and retrying things he may not have liked in the past”. The activity plan for the third resident details visiting family, college, keep fit, aromatherapy, shops, park and pub. Daily records for August do not evidence aromatherapy; keep fit, college, park and pub taking place. We also noted that this person requested to go to the cinema but records do not show if this was arranged. When we visited last time we asked staff to help residents plan more activities over the weekend that they can take part in. Although there is evidence that there are activities taking place during the week there is still limited activity at weekends. The home has its own mini bus. The Expert by Experience feels other forms of transport should be explored. As they state, “People that live here are all entitled to a free bus pass and should be encouraged to have one and be supported to use public transport, as this is a good way of involving people in the community”. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 17 Improvements with regard to residents having the opportunity to go on holiday have been made. The registered manager informed us that eleven of the residents are going on holiday this year, 2 to Great Yarmouth, 2 to Bournemouth, 3 to Minehead, 2 to Centre Parks and 2 with their families. She informed us that the remaining residents are going on daytrips as it is felt they would not benefit from an extended time away from the home. We explained that the home should evidence that the trips undertaken instead of a holiday are the financial equivalent to a holiday and above normal activities everyone can participate in. This will ensure people are treated equally. During the morning of our visit we witnessed tabletop activities being undertaken in one of the houses. Staff sat with residents helping them to complete puzzles and colouring. Residents appeared to enjoy these activities. During the afternoon in the same house we witnessed 3 residents and 1 member of staff sitting watching a DVD. We observed that the member of staff positioned a resident in a wheelchair directly in front of a resident sitting on the settee affecting their view of the television. We also noted that the member of staff sat separately from the residents. We discussed this with the registered manager advising that staff receive guidance in this area. At a previous inspection the home was advised to support residents who are able to plan and prepare their own meals. At this visit the registered manager informed us some work has been started but that further is needed. As she explained, “staff had problem understanding, some mother residents, but getting there, need integrating into care plans”. The Expert by Experience reinforced this. As they explained, “I then went on to ask who does the cooking and he said staff do, but sometimes he will help with the washing up. During my visit it was lunchtime and staff asked people what they would like for their lunch. I was pleased I heard people had choices, but feel they should have been supported to prepare their own lunches. As with the same house next door I felt people were being cared for and not being supported to live as independent lives as possible. Many people learn skills in the kitchen whether in previous homes or college and not having the opportunity to develop and cook their own food I feel is very wrong. The person did say the home use to have their weekly shopping delivered but this has recently changed and his goes shopping every week for the food. I asked if this was a better way and his said yes, its more flexible seeing what you want to get. I’m pleased the home has changed its way of doing the weekly shopping, as I think its important for people to go into their local community and carry out their shopping”. We indirectly observed residents when having their evening meals. In one of the houses we saw staff sitting eating the evening meal with residents. Residents informed us the meal was very nice, the atmosphere was relaxed and people appeared to be enjoying selves. Staff were not seen to be participating with the evening meal in the other 2 houses. The Expert by Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 18 Experience feels this might be due to lack of space in one of the houses. As they explain, “I noticed the dining table didn’t seem to have enough room for everyone to sit around at the same time so I asked how mealtime works. Staff said all the people sit around the table apart from the person in a wheelchair, as he needs support to eat, so staff sit with him in the lounge. Staff also said he doesn’t like the noise from others. I found this quite upsetting that due to lack of space and possible because he doesn’t like another, he is segregated in the lounge at mealtimes”. The Expert by Experience also spoke to a resident regarding meals finding people are happy with the choices offered. As they explained, “I asked what happens if the staff cook something he doesn’t like, staff said they always have an alternative on the menu. I was then shown a copy of a menu which showed all the meals 7 days a week with a 4 week change and they also change the menu during the summer and winter months. The person said they discuss meals they like at the residents meetings and staff listen. This was good to hear. On a Friday the menu said people choose a take away of their liking and the person said his favourite is fish and chips that he has and also enjoys a full English breakfast on a Saturday morning. I’m please this person is happy with the meals. I would like to see the menu be a bit more accessible for people. A picture menu may help people who find it hard to communicate to choose which meal they have. This will encourage choices for people”. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 19 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. In general the health and personal care that residents receive is based on their individual needs. EVIDENCE: All residents that we met were appropriately dressed for their age, the weather and gender. This promotes their dignity. A resident we spoke to confirmed they are happy with the support they receive with regard to personal care explaining, “my nails are varnished and toe nails, they are lovely”. In the main the health needs of residents are adequately managed. Further work is needed to ensure health records are accurate and up to date to ensure people’s needs are met safely. For example all 3 files we examined contained an accident and emergency grab sheet that staff use if a resident needs urgent medical attention. None of these have been completed in full and could result in health professionals not having all required information to treat a resident. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 20 Health action plans are completed for residents. As with other care records some sections of these were incomplete or do not give enough information in order to support residents with regard to their health needs. For example the section for recording injection information on one residents plan states ‘kept with GP’. As we explained to the registered manager this information should be obtained and recorded on file in order that the appropriate intervention is given if needed. She agreed with this. The same persons plan gave no information when last having a dentist or hearing appointment and did not evidence if they have attended a well man clinic. A multi-disciplinary review took place in June 2008 for this person where it was identified that the home needed to arrange for a hearing test. Records indicate this has not been arranged. A care plan is in place for nighttime observations that states this are to take place hourly due to epilepsy. We examined the seizure records for this person and found none to have occurred during the night. We discussed this with the registered manager explaining the possible intrusion on privacy and the need to be able to justify this practice. A professional visits sheet evidences the resident has been supported to attend health appointments with their General Practitioner and the chiropodist. Another residents ‘Every Day Health and Keeping Safe Plan’ states no health action plan has been completed, the section for recording if an annual health check has been undertaken is blank and states vaccination history not known. Other records on this persons file evidence all of this information to be in place. As mentioned in the care planning section of this report we discussed the issue of inconsistencies with records with the registered manager. This person has a care plan for personal care and a moving and handling assessment that compliments the contents of the care plan. This helps ensure the resident receives the support is the way they need. A professional visits recording sheet for this person details appointments for a medication review, blood tests, weight monitoring and appointments with a nurse for dressing to be changed. This is positive as it demonstrates the resident is being supported to manage their health needs. We found records of twenty other health appointments that have not been included on this monitoring sheet. One of these for a visit to the dentist December 2007 that instructs a follow up appointment in 6 months time. We could find no evidence of this taking place. We discussed this with the registered manager advising a review of recording systems to ensure the health needs of residents are monitored effectively. One resident who is a wheelchair user has been assessed by an Occupational Therapist May 2008. The resulting report states when visiting the home the hoist was not working and that staff on duty say that 3 people are needed when showering. We spoke to staff about this who informed us 2 staff are needed to assist. They also stated about the resident, “hates the hoist, tend not to use it”. We observed that the hoist was stored in a part of the home with the vacuum and a large heavy pile rug is placed in front of the resident’s bed. This leads us to question if the hoist is used. We informed the registered manager that a hoist must be used unless a suitably qualified person such as Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 21 an Occupational Therapist assesses this is not in the best interests of the resident. We also advised that the provision of an electric hoist be explored, as this might be more comfortable for the resident. In the main there are good arrangements for the ordering, receipt and safe storage of medication. The home uses a monitored dosage system that is maintained separately in each of the 3 houses that make up the home. Since the last inspection residents have been assessed as to whether they are able to self medicate. This is positive as it supports people to be independent. We noted that one person achieved a score rating of 7 out of a possible 9, indicating they are able to self medicate but then staff have recorded that they are unable to do this. We discussed this with the registered manager explaining that if someone is assessed as able then they should be supported to manage their own medication. We also discussed the various levels of selfmedication that residents could undertake, dependant on each person’s capabilities. One resident’s care plan for medication states that medication is to be crushed. It does not make reference or evidence the General Practitioners consent to this and no risk assessment in place. We informed the registered manager crushing of medication can affect how the body absorbs it and consent must be obtained to safeguard the resident’s health. Staff have received training from the dispensing pharmacist. Craegmoor have now introduced a competency assessment for all staff that administer medication to ensure that they are safe practitioners and are not placing residents at risk with poor practice. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 22 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. Systems are in place to support residents to complain. Further improvements would encourage suggestions to improve the service being provided. The monitoring of behaviours and incidents must improve to offer sufficient safeguards to residents. EVIDENCE: Residents meetings take place where they are encouraged to offer their views about how the home is run. Residents are sometimes asked if they have any concerns or complaints during these meetings. It was recommended during the last inspection that this be added as a set topic for discussion on the agenda, this recommendation will remain. Since the last inspection the complaints procedure has been produced in pictorial format and is included in the service user guide. The Expert by Experience talked to a resident and staff about complaints. As they explained, “I asked who does he talk to if he is ever unhappy and the person said staff. I asked if they do anything about any problems and he said sometimes. Staff said they have a grumble book they encourage people to use and showed me it. The grumble book has not had anything written in it since August 2007. So I’m not sure how effective the book is and if staff are encouraging people to use it, is it taken to residents meetings or is it written down somewhere else?” Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 23 There has been one Adult Protection referral since we last visited the home. This was made by the home to ensure a resident was not at risk of harm. The Expert by Experience found that it might benefit residents if further work is undertaken to ensure they understand their rights to be protected. As they explain, “I asked the person how he feels about complaining about anything that troubles him, he said he would talk to staff but it can be a sensitive issue. We talked a bit about abuse and the importance of reporting it but he said it’s a sensitive issue. I feel the home should discuss with people more about what abuse is, the types of abuse that happens and what to do about it. I think its needs to be talked about so people aren’t afraid of reporting it and feel shy about talking about abuse”. When examining care and accident records we found that there have been occasions when residents have sustained unexplained injuries. For example a body map for one resident has been completed detailing scratches to both breasts and a bruise to lower stomach. An accident record for another record states that a resident claims their fingers were bent by another resident resulting in bruising and swelling on left hand. No safeguarding referrals have been made in line with local authority procedures and the commission was not notified in line with Regulation 37 of the Care Home Regulations 2001. Due to our concerns in this area we issued an immediate requirement form at the inspection instructing that this practice must cease with immediate effect in order that residents are protected from harm or abuse. It is pleasing to find that the majority of staff have undertaken protection of vulnerable adults and aggression training. We sampled the personal finances and records of 3 residents. All were in good order and up to date. Inventories of personal belongings are maintained for each resident. These would benefit from being updated, as some have not been completed for over twelve months. Some of the people living at this home have behavioural needs that require support from staff. Care plans are in place to inform staff but some need further development to ensure people are not placed at risk. For example the care plan for one person has no information apart from ‘refer to reaction plan’. The reaction plan is dated 2004 and states to give diazepam if behaviour escalates. A member of staff informed us that the resident has not required diazepam for some years but it is stocked in case of need. Neither of the documents detail the need for staff to undertake physical intervention training or for behavioural monitoring records to be completed. Incidents of aggression were found to be recorded in the resident’s daily records but monitoring charts and accident records were not completed. We discussed this with the registered manager instructing that the behaviour plans for this person be reviewed and amended to ensure they contain detailed information that supports staff to assist the resident and allow for effective monitoring. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 24 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 adequate. This judgement has been made using available evidence including a visit to this service. In the main residents live in a safe and comfortable environment. Improvements to facilities will encourage independence. EVIDENCE: It was pleasing to see that there have been improvements to the home since our last visit. Most of the residents have had their bedrooms redecorated. Some of the rooms were seen and were pleasantly decorated and reflected people’s likes and dislikes. Rooms were personalised with their own belongings and were all clean and tidy. A kitchen and office have also been decorated and the gardens tided and replanted. The registered manger informed us new flooring is going to be fitted in all communal areas and that all bathrooms and toilets are going to be refurbished. This is good investment by the company that owns this home and helps promote a comfortable and safe place for residents to live. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 25 Both house 83 and 85 have their own front doors, however none of the residents enter their home this way. Access to the all of the homes is through house 81. This means that those residents’ who live in house 81 are being constantly disturbed by visitors, and other residents walking through their home to get the other houses. It was also observed during the inspection that if no staff are available to answer the door in house 81 visitors will ring the doorbell until someone in the other houses hears them. This is not ideal and does not always offer a relaxing environment for residents and should be reviewed. There is no designated smoking room in any of the houses, at present residents have to stand outside under the entrance to a laundry. This is not compliant with the Smoke Free Regulations, as a permanent entrance cannot be used as a designated smoking area. There are two laundries, one in house 81 and a shared laundry for 83 and 85. There were some improvements noted such as gloves and aprons and liquid soap being available for staff use to reduce the risks of cross infection to residents. Mops continue to be stored head down in buckets and are not being washed in line with current best practice. The walls of the laundry under house 85 are peeling and plaster has fallen of the walls, this must be addressed it has been outstanding for the last two inspections. The home should contact the Health Protection Agency for advice with regards to the laundry and implement any recommendations made. This will promote good infection control within this facility. The improvements and areas still needing attention were also identified by the Expert by Experience. As they explain, “On arriving at the home today I first thought it was good to see the home located in a busy place with shops and pubs nearby. Shortly after I arrived I met the manager who appeared very friendly and helpful and made me a cup of tea and I felt very welcomed. The home has 3 different houses all next door to each other. The manager first showed me to the house 2 doors away. The manager took us to the home through the back door of the house I arrived in, then across the garden into the back door of the other home. Having 3 separate homes I felt it would have been more appropriate to go to the front door of the home and knock on the door. I feel this is more personal to the people that live in and I would have felt more comfortable and respectful to people living here as a visitor, entering the home through the front door. I asked a person how long he had lived here for and he said for a long time, about 12 years. He said the home didn’t use to be very nice but it is a lot nicer now and said it had recently been redecorated. I asked if there was anything he could change about the house if he was able to. The person said he would like his home to have it own laundry, as the laundry is next door in the cellar. In every persons home they should have their own washing machine and be supported to do their own washing, I feel this needs to be addressed. The person that I spoke with said he is a smoker, but as the laws have changed he is no longer to smoke in his Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 26 home and has to smoke outside, which he understands. From what I could see in the garden the home has not provided any sort of shelter for people who smoke in the home. The home needs to address this issue especially before the winter months. During my visit I notice people and staff move in-between the 3 homes through the back doors and don’t seem to knock when they enter. It’s a shame its so easy for people to move about the different homes as it doesn’t make it a very personal home to those that live in it. I found it disrespectful to be going in and out of homes like this and not knocking on the doors. People should be encouraged to use their own front doors, along with others that would like to visit”. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 27 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): 32,33,34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are generally trained, skilled and in sufficient numbers to support the people living there. EVIDENCE: In the main staff that we spoke to appear to understand their roles and responsiblities and the needs of people they support. The Expert by Experience was also of this opinion, explaining, “I first met a person who was sat in the dining room with a member of staff I introduced my supporter and myself. Staff helped me to meet the person, as he did not use words to communicate. I asked staff how people communicate with the person and what things does he like to do. The staff member said she didn’t really know the answers as she does not normally work in this house and would get another support worker to come and talk to us. I was really disappointed this staff member working with this person and didn’t seem to know what he likes to do. This is very worrying especially as the person has limited communication and its key for staff working with him, to know about his needs and wants. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 28 The other staff member did seem very knowledgeable about the person and said the staff that regularly work with him knows how to communicate with him. I saw him make a gesture with his lips and staff said would you like a cup of tea and he made a sound to say yes. Staff then made him a cup of tea straight away. I was pleased to see staff acting straight away”. When giving feedback to the registered manager she said that she had changed the houses some staff work in as they have become too familiar with residents and this is affecting how they support them. She is hoping that the changes in staff will enable residents to undertake more independent living skills. Since the last inspection staff has undertaken a lot of training. This ensures they have the necessary knowledge to support people living at the home. There are currently 24 staff employed at the home, 21 have received epilepsy training and 22 autism. The registered manager informed us some staff have undertaken Mental Capacity Act training and further training is arranged for the end of August 2008 for the remaining staff. Also 73 of staff either hold or are in the process of completing a National Vocational Qualification (NVQ) level 2 or 3. Also since the last inspection shift patterns have changed for staff working at the home with staff undertaking twelve-hour shifts from 8am to 8pm. A previous recommendation to ensure staff do not exceed the 69 hours a week as indicated in the homes own risk assessment is now met. The registered manager informed us that staff work 48 hours one week and 36 the next. She also informed us that there are currently no vacancies apart from 2 night shifts, which are covered by part time night workers. This improvement in the stability of the staff group is a benefit to residents as it helps ensure they receive consistent support. We viewed staff rotas and found that between 6 and 7 staff are on shift morning and afternoon and 4 during the night. Rotas show that shifts have not been covered when staff take annual leave, maternity or sick leave. On some occasions this has resulted in 4 staff being on duty during the day. We discussed this with the registered manager explaining this not acceptable as this impacts on the quality of service residents receive. The home continues to recruit people in ways that safeguard residents. It was pleasing to see that all of the staff files seen had Criminal Records Bureau (CRB) disclosures, 2 references, forms of identification and an application form. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 29 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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In the main management of the home ensures residents health and safety is being promoted. Further improvements will ensure residents receive a consistent level of service. Systems for monitoring quality continue to be implemented. EVIDENCE: Ms Claire Booth became the registered manger at Alphonsus House in June 2008 after commencing employment there in February 2008. She is a Registered Learning Disability Nurse and has recently completed the Registered Managers Award. Ms Booth has many years experience as a manager of care homes including those for people who are deaf and/or have mental health problems. Ms Booth was present throughout our inspection and Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 30 presented as committed to continuing to improve the quality of service people living at the home receive. She recognised work is still required and offered assurances that actions will be taken to address this. The company’s quality assurance programme is ongoing. The Company has developed its own Clinical Governance Team which supports and audits care delivery. There are audits that address the environment, infection control and medication and recently health and safety. We discussed with the registered manager how the views of residents and stakeholders in the community are obtained and incorporated into the quality assurance programme. She informed us that Craegmoor have re-issued residents questionnaires, that she has sent questionnaires to families but not to outside agencies as of yet. Residents meetings have been reinstated as another way of obtaining views (as previously mentioned work needs to take place to evidence action is taken to address issues identified from these). A summary report of residents’ views has been published for July/August 2006. This gives findings for all users receiving a service by Craegmoor. The registered manager was unaware if an updated summary was available. Before we carried out this inspection we sent questionnaires to residents living at the home. Twelve were returned, all completed with assistance from staff at the home. All indicate they are happy with the service provided by the home, with no issues identified. We discussed this with the registered manager, questioning if the responses were a true reflection of residents opinions. The registered manager informed us that she had sent questionnaires to residents and invited us to view the findings. These give a clearer view of residents’ opinions. For example with regard to the internal environment 10 state the home is free from odours, 2 not happy and not free from odours, 7 furniture not appropriate, 12 there is always clean linen, 1 wanted a fire in lounge, 1 not happy with décor in bedroom and 12 that staff respond quickly to their needs. We discussed the in-house questionnaires with the registered manager as these give different responses to those completed with assistance of staff for CSCI. She stated staff would not have been as honest due to being for CSCI. We strongly advised that other support networks be explored for assisting residents to complete external agency questionnaires in order to obtain true reflections of residents’ views. As in previous inspections maintenance records were spot-checked and records were generally in order. There are now records of regular fire checks being undertaken, this includes lighting and alarms. Records are also in place for fire drills but these would benefit from being expanded to include the names of people. This will help monitor all staff, including night staff regularly participate. One area that improvements should be made is that of monitoring of accidents. We viewed the accident records for 2008 and found that in some instances notifications in line with Regulation 37 of the Care Home Regulations 2001 and critical incident forms (forms required by the organisation that owns Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 31 the home) have not been completed. We discussed this with the registered manager who confirmed an analysis of accidents and trends is not undertaken. She stated she was not aware of some accident records and informed us she would need to review the current system to ensure she made aware of all incidents and accidents. Since the last inspection the majority of staff have undertaken basic food hygiene, fire safety, first aid, health and safety and manual handling training. This helps ensure residents’ safety is maintained. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 32 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 3 3 X 4 2 5 X 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 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 1 12 1 13 1 14 1 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 X 2 X X 2 X Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 33 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation 12(1) Requirement Health records of residents must be accurate and up to date to ensure people’s needs are met safely. A hoist must be used unless a suitably qualified person such as an Occupational Therapist assesses this is not in the best interests of the named resident. Referrals in line with local authority safeguarding procedures must be made for any unexplained injury to a resident. This will help protect them from harm. Staffing levels must be maintained when people take annual leave, maternity and sick leave. This will ensure residents’ needs are met by safe staffing levels. Timescale for action 30/09/08 2 YA19 13(4)(6) 19/08/08 3 YA23 13(6) 18/08/08 4 YA33 12(1) 01/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 34 No. 1 Refer to Standard YA4 Good Practice Recommendations Trial visits should take place not only so that the home can be confident of meeting new residents needs but in order that an assessment of compatibility of others already living there is undertaken. Contracts of residency should be produced in different formats to help people to be aware of their rights and responsiblities. Staff should receive further guidance relating to the compilation of key worker meetings in order that they read as an overview of events from each month. Work should continue to ensure specific care plans are implemented for all identified needs. If a resident is unable to be involved in the compilation and reviewing of their care plans then advocates or family should do this. A review of residents’ care planning documentation should be undertaken to ensure all is maintained accurately. This will help ensure residents’ needs are met. Action should be taken to evidence requests made by residents to ensure their views are acted upon where possible. Work should be undertaken to evidence decision-making protocols undertaken when the decision is made that a person lacks capacity. The home must be able to evidence compliance with the Mental Capacity Act. This will help promote peoples rights. Risk assessments should be completed for all identified needs. These should contain sufficient information to inform staff how to support residents and minimise risks. All residents should be supported to participate in activities both in and outside of the home. Residents, who are dependant on staff, should be supported to participate in a range of stimulating activities both in and outside of the home that meet their needs. The sensory plan completed by the O.T should be implemented for a named resident to ensure their needs are met. Residents who are entitled to a free bus pass should be encouraged to have one and be supported to use public 2 3 YA5 YA6 4 YA7 5 6 YA9 YA13 Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 35 transport, as this is a good way of involving people in the community. The home should evidence that the trips undertaken instead of a holiday are the financial equivalent to a holiday and above normal activities everyone can participate in. This will ensure people are treated equally. Residents who are able, to should be supported to plan and prepare their own meals. A picture menu may help people who find it hard to communicate to choose which meal they have. This will encourage choices for people. A hearing test must be arranged for the named resident as identified in their multi-disciplinary review June 2008 to ensure their needs are met in this area. Due to the possible intrusion on privacy, the home must be able to justify the practice of hourly checks on residents during the night. That the provision of an electric hoist be explored, as this might be more comfortable for the named resident. If a resident is assessed as able then they should be supported to manage their own medication. Consent must be obtained to safeguard the resident’s health for any medication that is crushed. Concerns and complaints should be included as a set topic for discussion on residents’ meetings agenda in order to support people to raise concerns. The grumble book should be reinstated and all residents made aware of how this can help them raise issues. The home should discuss with residents what abuse is, the types of abuse that happens and what to do about it. This is so residents will not be afraid of reporting it and feel shy about talking about abuse. Inventories of personal belongings would benefit from being updated, as some have not been completed for over twelve months. The behaviour plans for a named person should be reviewed and amended to ensure they contain detailed information that supports staff to assist the resident and allow for effective monitoring. A designated smoking area that is compliant with the DS0000004837.V369892.R01.S.doc Version 5.2 Page 36 7 YA17 8 YA19 9 YA20 10 YA22 11 YA23 12 YA24 Alphonsus House Smoke Free Regulations should be provided for residents. Access to each house should not be shared. This will promote a more personal feel and be more respectful to people living there when visitors arrive. The home should contact the Health Protection Agency for advice with regards to the laundry and implement any recommendations made. This will promote good infection control within this facility. Other support networks should be explored for assisting residents to complete external agency questionnaires in order to obtain true reflections of residents’ views. Fire records would benefit from being expanded to include the names of people. This will help monitor all staff, including night staff regularly participate. Notifications in line with Regulation 37 of the Care Home Regulations 2001 and critical incident forms (forms required by the organisation that owns the home) should be completed for accidents/incidents. An analysis of accidents and trends should be undertaken to inform future practices. 13 YA30 14 15 YA39 YA42 Alphonsus House DS0000004837.V369892.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V369892.R01.S.doc Version 5.2 Page 38 - 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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