Inspection on 24/01/06 for Alphonsus House

This inspection was carried out on 24th January 2006.

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

The inspector found 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 83 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alphonsus House 18/08/08

Alphonsus House 22/08/07

Alphonsus House 12/12/06

Alphonsus House 16/06/06

Alphonsus House 07/12/04

Alphonsus House 29/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Alphonsus House 81 - 85 Vicarage Road Oldbury West Midlands B71 1AH Lead Inspector Debbie Sharman Unannounced Inspection 24th January 2006 10:00 Alphonsus House DS0000004837.V280528.R02.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.V280528.R02.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.V280528.R02.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 Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Alphonsus House DS0000004837.V280528.R02.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. 21 October 2005 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 its own facilities (although house nos. 83 and 85 share a communal laundry located in the cellar). The Manager’s office is located in house no. 81. 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 no. 81 with space for one car. Car parking is on the main road outside the three properties. The Home has 14 single bedrooms and 4 double bedrooms situated on the first and ground floors. Access to the first floors are via a stairway. Each property contains a dining room and a lounge. There are three domestic style bathrooms and toilets. Two houses also have a shower (although not level access). Each house has its own dedicated staff team although staff may work in all three houses to cover absences if required. Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two Inspectors from 10.00am to 6.30pm carried out this unannounced inspection. As it was unannounced the Provider, Manager, service users and staff did not receive prior notification and were not able to prepare. The Acting Manager was available to support the inspection throughout the day. The Area Manager responsible for the home was present for part of the day. The plan for this inspection was several fold - to assess performance against those National Minimum Standards that were not assessed at the inspection in May 2005, to assess progress made by the home in meeting requirements issued for improvement from all 4 inspection visits carried out since May 2005 (May 6, July 8, July 19 and October 21st 2005). Any requirements met from reports issued at these inspections have been deleted but any that remain outstanding have been accumulated and brought forward into this report. It is acknowledged that not all requirements were assessed at this visit and action may have been taken to address some areas, these will be deleted from the report following the next statutory inspection of the service. An additional visit to the home took place in August 2005 and was carried out by the Commission for Social Care Inspection’s Pharmacy Inspector. Requirements arising from that visit were not assessed at this visit as the Pharmacy Inspector will reassess them, but the requirements made have also been amalgamated into this report. An additional purpose of this inspection was to assess compliance with 2 of 3 legal Enforcement Notices issued in respect of the home on December 8th . Requirements arising from these notices are included in this report. These notices relate to records management including the staff roster and the management of service users nutrition. The third notice was not assessed as the time period for compliance had not at the time of inspection elapsed, however progress was discussed. The Inspectors assessed documentation, observed practice, spoke with both the Acting Manager and Area Manager, briefly toured parts of the environment and grounds chatting to service users, and interviewed a staff member. The plan is for the Commission for Social Care Inspection to meet with the Manager/s of the service following publication of this report to agree priority areas for improvement. What the service does well: The Manager and staff continue to welcome and work cooperatively with Inspectors during the inspection process and, together with the provider, continue to state their commitment to making the required improvements - of which some have been evidenced at this inspection. Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 6 Hazardous chemicals are now stored safely and this protects service users from the risk of harm. The grounds are pleasant and well maintained and the communal areas of the home are clean, domestic in style and fresh smelling. Service users are supported to maintain contact with family who are invited to attend parties and meetings arranged. Menus are varied and the menu was adhered to on the day of inspection. An array of national and local adult protection procedures were readily available for staff and service users (in pictorial form) to inform and guide in the event of there being an incident or concern. What has improved since the last inspection? What they could do better: The management of the staff rota remains inadequate and the home is in breach of a legal notice issued in December 2005. Poor management of the rota undermines accountability and staffing levels and consequently risks service user safety and care provision. It is a key document in the management of a residential service to vulnerable adults. Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 7 The requirement to make the crazy paving safe has been met, but disappointingly the provider has not simultaneously ensured the replacement of adjacent uneven slabbing which remains a tripping hazard. The home continues to provide care and accommodation for service users with a physical disability for whom the premises are not sufficiently suitable. Lack of space also compromises storage of food, with stocks for house 85 being kept in house 81. The effect of this was found to impact on care practice. Whilst nutritional outcomes for some service users assessed have improved the Manager must ensure that food identified in care plans to support weight gain are stocked and readily available / accessible. Infection control practice is not robust with staff demonstrating little understanding of the risk of cross infection. Staff coats and bags are being stored in the kitchen and garden furniture cushions are stored unprotected on open shelving in the laundry. There is no soap or paper towels in this high risk area. Record keeping requires general improvement. Assessments are not signed and dated making it difficult to judge that assessments of service users needs are up to date. Care plans are insufficient (e.g. moving and handling, choking, behaviour management). They do not provide staff with sufficient guidance even where immediate requirements have been issued to ensure this and where verbal assurance of improvement at multi disciplinary review have been given. Care plans and risk assessments continue to be not sufficiently specific. Food intake records for one service user on one day had been completed prior to the meal being eaten and following a change of plan and meal were therefore inaccurate for a service user at nutritional risk. The manager has not received sufficient formal supervision and neither have the staff. There was no evidence of performance management support for staff where this had been identified as required by the manager. Staff training is not sufficiently available with training that provides specific knowledge (such as risk assessment training, diabetes training, nutrition training) not being available. Mandatory training is also not sufficiently available. The Commission for Social Care Inspection is concerned that it receives repeated written assurance that fire and adult protection training has been provided for all staff when inspection shows this not to be the case. Fifty percent of staff have not achieved NVQ level 2 qualifications by 2005, the target date. This does not support staff to gain sufficient knowledge to meet service user need and maintain their safety. Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 8 The provider must improve its processes in response to allegations and complaints, including referral where required to the national list which identifies care staff considered to be a risk to vulnerable service users. A referral following an incident in April 2005 has still not been made. This inspection highlighted 2 additional allegations requiring disciplinary investigation had not been notified to the Commission for Social care Inspection as required by regulation. 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.V280528.R02.S.doc Version 5.1 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.V280528.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Assessed needs, risks and care plans are not sufficiently comprehensive, up to date or adequately reviewed and do not adequately guide staff to meet service user needs. EVIDENCE: No new service users have been admitted to the home. There is a stable service user group who are all permanently resident and the home is fully occupied. Assessments were therefore inspected in respect of an existing service user. An Outcome Based Evaluation assessment tool was in place and had been completed. It had not been dated or signed by the staff member who completed it and therefore there is no evidence of how in or out of date this is with no evidence that the assessment of need is being periodically reviewed. Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Care plans are not sufficiently comprehensive, specific or regularly reviewed to assure service users that their assessed and changing needs are fully reflected in their individual plan. EVIDENCE: A Service Users care plan was assessed. Nutrition and behaviour guidelines were included and provide adequate guidance. The mobility care plan has not been reviewed properly since September 2004. Epilepsy guidance is insufficient and is not dated or signed. Health screening where the service user is not able to consent has not been adequately addressed. Agreed arrangements for family contact are not included. There is some reference to financial assistance but this is outdated and not realistic. There is no reference in the care plan to cultural or faith needs. The care plan does not consider consent issues in respect of the need for 2 staff to be present whilst personal care is provided and there are no contingency arrangements in place in the event of consent not being given. Care plans are not sufficiently specific. For example reference to the need for ‘frequent checks throughout the night’ does not adequately guide staff and is open to a variety of definitions. Similarly the care plan for a service user at nutrition risk refers to the need for ‘small meals but often’. A moving and handling care plan for a dependent service user still Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 12 refers to ‘using agreed techniques’. This does not sufficiently guide staff to know which techniques and with what equipment. Similarly a behaviour care plan for a second service user continues to state ‘ in the case of an extreme outburst 2 staff are to support’. This does not guide the staff as to how they are expected to provide such support. This feedback was given at the previous inspection. Reviews of care plans are not sufficient with evaluations consisting of ‘care plan active’. Care plans are not in a format suitable for service users and person centred planning is limited. There are three different risk assessments in place addressing falls but are not comprehensive with all risks and hazards not considered. The premises are not suitable for adults with a physical disability. Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 17. Service users have appropriate personal and family relationships. Service users are offered a varied diet with some improved nutritional outcomes for service users at risk. Foods to fully meet service users identified and specific nutritional needs and choices are not sufficiently available. EVIDENCE: Family contact is not sufficiently addressed in care plans but discussions with staff showed that family are invited to attend care plan review meetings and important events such as birthday parties and had been invited to a Halloween party held in October 2005. The Inspector attended a multidisciplinary review for one service user in 2005 and the inclusion of the service users significant relative was evidenced. Meals and nutrition were assessed to gauge compliance with legal notices issued in December 2005. There has been an improvement in outcomes for service users. Both service users case tracked have put on an encouraging amount of weight in a short period of time. Records assessing need and risk including plans to guide staff and monitor food provided whilst not perfect have Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 14 generally improved. Staff are now talking about and understanding the need to fortify meals for those service users at nutritional risk. Records evidence some fortification. But whilst inspection of food stocks showed menus being adhered to stocks held do not fully comply with the requirements to fortify diet as detailed in the plan of care. Examples of this being the identified and recorded need to provide full fat yoghurts and milk. Inspection showed all yoghurts on the premises to be low fat and milk to be semi skimmed rather than full fat. House 85 is having (because of restricted storage space) to replenish its food stocks from the fridge of house 85 and this compromises practice. For example cream was not added to a service users breakfast that morning as house 85 had run out but there was some in house 81 that had not been fetched. Fresh vegetables were not available in house 85 and have to be fetched from house 81 as the food is ordered, delivered and stored there. The staff member explained that if none were left they would use frozen vegetables disadvantaging service users in the other two houses. For example carrots and baby potatoes were on the menu for that evening in house 81. Inspection of stocks in house 81 including those delivered at that time showed there to be no baby potatoes and no carrots. Those aspects requiring further improvement were relayed to the Manager and Area Manager. There was evidence that nutritional risk assessments had been reviewed and redone in November 2005 but the score indicated that there was a need to re do this after 4 weeks. This had not been done. The care plan says ‘to eat small meals more often’. This is not sufficiently defined for staff but records showed that an extra snack (e.g. biscuit) was at times being provided. Records of meals eaten are being maintained but a staff member had completed the entry for lunch prior to lunchtime. The result of this was that the record was not accurate as the service user had declined the lunch (sandwiches, crisps, apple) and had a tin of soup instead. Like medication records food intake records must be completed after the meal has been eaten in the interest of accuracy. Referrals have been made via the GP to the dietician service for support as required but the manager said that she has received a letter to state that this service is not available for learning disabled clients. Securing the services of a private dietician paid for by the provider has not been considered. Staff confirmed that they are providing one to one support for a service user at high risk of choking at meal times and when food is present. Care plans however remain insufficient. High risk and suitable foods for pureeing have not been included in guidance. Evidence obtained at a previous inspection showed the service user to be choking on bread and cakes and an immediate requirement was issued. Although written guidance has been received from an appropriate service about pureeing food, including safe ways of pureeing bread and cake, the advice has not been transferred into care plans to reduce the risk from such products. Staff are therefore not sufficiently guided. A service user said he had enjoyed the lamb dinner. Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not assessed at this inspection. Requirements issued for improvement by the Pharmacy Inspector in August 2005 have been amalgamated into this report. A dependent service user whose moving and handling has been previously subject to immediate requirement for urgent improvement was observed being transferred to a wheelchair in a manner that is not consistent with good practice (under arms) and not in accordance with how the Acting Manager described. However the moving and handling care plan remains insufficient and fails to guide staff referring only to ‘use agreed techniques’. In addition the Acting Manager explained that staff are walking this service user within the premises. This is contrary to the guidelines put in place in response to the issuing of immediate requirement prior to this Acting Managers appointment to post. The Manager must ensure that this service user is moved and handled in a safe manner that also considers the dignity of the service user. Written guidance must be sufficient. Alphonsus House DS0000004837.V280528.R02.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. Service users complaints are responded to but investigation performance is unsatisfactory. EVIDENCE: Complaints procedures are in place and are available in both pictorial and audio formats. The Acting Manager reviews any complaints received quarterly although none have been received between June 2005 and December 2005. The Inspector remains concerned about the provider’s ability to investigate complaints and disciplinary issues. A disciplinary investigation as a result of a complaint raised by a service user in April 2005 was contradictory and insufficient in scope. One element of the complaint considered as part of the disciplinary was not upheld by the provider’s appointed investigator after it had been upheld following investigation by the Commission for Social care Inspection. The provider had been notified in writing of the outcome. However the relevant authorities had been notified appropriately upon the home becoming aware of the complaint as there were adult protection implications. Although protection was not fully assessed it was pleasing to note that an array of documentation was available on notice boards to guide both staff and service users about abuse and action to take. The homes policy is not fully compliant but a copy has been provided to the home who now have national and local guidance available to them on the premises. Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not fully assessed but progress towards meeting previous related requirements was assessed and some improvement is noted. For example window restrictors have been fitted to all windows. The storage of hazardous chemicals is now appropriate. Mops in the laundry were dry, clean and stored appropriately. The flooring in the laundry has not been replaced but has been patched and provides a satisfactory cleanable surface. The long outstanding improvement to the uneven paving at the rear of house 81 to provide an even and safe surface disappointingly has been partly met. The requirement to replace the ‘crazy paving’ had been literally responded to, removed and concreted. But the smaller area of very uneven slabs attached but which forms part of the same patio area had been left. The Area Manager offered to ensure that this unsafe paving is replaced within the next two weeks. The laundry remains a concern. Paint on the ceiling is badly peeling and flaking. Whilst the storage of mops and the flooring have improved and were clean, performance in other ways remains unsatisfactory. For example there was no soap or paper towels available for staff to wash their hands after Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 18 handling soiled linen. There was clean wet, clean dry linen and ironing boards left unprotected in the laundry increasing the possibility of cross infection in such a small area. Three large cushions used on outside furniture in the summer were also stored unprotected in the laundry increasing the risk of the spread of infection through cross contamination. The laundry must not be regarded as a storage area. Similarly on arrival the Inspector found staff coats and bags stored on kitchen surfaces which is poor infection control practice. Occupational therapy advice about the premises has not been obtained as required in respect of identified service users with mobility needs. The Acting Manager said that she knows that the premises are unsuitable for the identified service users and that another occupational therapy report will only confirm this again. This requirement has therefore been deleted. However as the Manager has concluded that the home is unable to satisfactorily meet the needs of these service users, appropriate action must be taken. A new television has been provided in house 85. The display of Adult Protection, Whistle blowing and complaints literature in house 85 is commendable and an improvement but does not make for a homely ambiance in the dining room. An alternative but accessible site would be preferable. Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 36 The staff team is not yet sufficiently competent or qualified. Recruitment practices are not fully protecting service users. Staff meetings, supervision meetings and written guidance available to staff, including where performance is identified as a concern, are insufficient and therefore staff currently are not sufficiently well supported and supervised. EVIDENCE: Inspectors were told that eight staff out of 23 have completed their NVQ training but 6 certificates that were awaited at the last inspection in October are still outstanding and could not be verified. This does not meet the target of 50 qualified by 2005. The training programme does not include all specialist training required. Subsequently the specialist training included as previous requirements such as nutrition training, risk assessment training have not been met. As at the last inspection some staff have not received Fire training or adult protection training. Three staff have not received fire training since July and December 2004 and this is seriously out of date. A staff member appointed in October 2005 has also not received fire training. Three staff have not received Adult Protection training in spite of recent written assurance provided to the Commission for Social Care Inspection to the contrary. The Acting Manager said that Fire Training had been cancelled by Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 20 the trainer and was to be rearranged next week. Adult Protection training has been booked for 10 February 2006. The frequency of staff meetings has improved with 4 meetings being evidenced between May 2005 and January 2006 (only half the staff team were present for the meeting in January 2006). A further increase in the frequency of meetings would better support staff to make the improvements to accelerate the required improved performance of the home. Given the issue of legal notice in December 2005 to improve the management of records and rotas, the rota was assessed. The outcomes evidenced that the provider is in breach of the notice issued. The paper rota is not an accurate representation of hours worked. A new electronic ‘clocking in’ system cannot be considered the equivalent as Inspectors were told that data had not been inputted correctly and that any changes made electronically are not stored. The rota was not clear with one entry appearing to be crossed out with it being uncertain whether that staff member had worked and which shift she’d worked if she had. Inspectors cross-referenced to the electronic system but data had not been inputted correctly. Inspectors were initially told that the staff member had in fact worked that day but this was later retracted and Inspectors were told that she had in fact not worked and the shift had been covered by two staff, the second of whom is not on the actual rota. Shifts that are not worked need to be made clearer including the reason for not working e.g. sick, annual leave etc. Furthermore a staff member who has been suspended from duty was included for the suspended shifts on the duty rota as having worked. As an alternative staff member had covered her shift, the rota gives the appearance that more staff were on duty than were. The Acting Manager had introduced a planner in addition to the rota but this appears to have caused confusion as the two documents contradict each other and staff had taken to altering one and not the other leaving an unclear record. The managers preferred format for the rota where times are stated rather than a coded system had not been persevered with. Although the first was felt to be more accountable staff had struggled with it and the less effective system was reverted to. The handy man is not included on the rota although he works at the home three days per week. The explanation being that this is because he is not funded by the home but borrowed from the adjacent sister home, compounding lack of clarity and accountability. Recruitment checks appertaining to agency staff are up to date demonstrating improvement. Recruitment checks were assessed for a newly recruited staff member. Required systems are partly but not fully met. The staff member had declared whether there were any previous criminal offences, gaps in employment history had been explored, history of health obtained and a photo was in place. However although two references had been obtained one was not from the last employer. Receipt of the POVA had been confirmed to the home in an email from head office. An assumption that it was satisfactory had been made as this was not explicit and a copy of the POVA first check was not Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 21 available as required. Similarly identification for the new staff member was not available. It was said to be at Head office. It must be held at the home. A Criminal Bureau check has not been obtained prior to appointment as is good practice but a risk assessment has been undertaken. Control measures have not been put in place for escorting away from the premises and there is not a named supervisor. There is no record of supervision for this new staff member in spite of the raised risk of him taking up post prior to receipt of a Criminal Record Bureau check. Supervision records for a night staff member were inspected. The frequency of supervision is not meeting the national minimum standard. This staff member had in 12 months received two supervisions (Feb 05 and Jan 06). Records of a third supervision were available but were not dated. Irrespective of this as six are required as a minimum in a 12-month period this staff member had not been sufficiently supervised. A senior staff member whose performance was said to be being supported had received one supervision in July 2005. Two disciplinary investigations were instigated in December 2005 and January 2006 in respect of two staff members in unconnected circumstances. The Commission for Social Care Inspection was not notified. The incidents came to light during this inspection. The first was recorded, investigated and concluded by the Acting Manager and disciplinary records were available. Control measures had been put in place as a result of the outcome. The second incident is being investigated currently. Alphonsus House DS0000004837.V280528.R02.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 Service users are benefiting from an improvement in the management of the home. EVIDENCE: The Acting Manager has since the last inspection applied to the Commission for Social Care Inspection to be registered as the Manager of Alphonsus House and has been interviewed. The decision is awaited. She has achieved her Registered Managers Award and is doing her NVQ 4 in Care currently. Evidence has been provided to show that the Acting Manager has also undertaken training to update her knowledge and skills. The Acting Manager has received only two formal supervisions since her employment in May 2005 and does not have a job description to guide her in her role. The Area Manager expressed disappointment and concern about findings demonstrating non compliance with the legal notice to improve rotas. He feels the home has made improvements and was frustrated by inadequate performance verbally expressing a strong desire for the home to improve to Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 23 meet the National Standards. A staff member expressed concern about being ‘shouted’ at as a result of the assessed outcomes. Some previous requirements have been met and there are some improved outcomes for service users. Progress however is in some areas not happening or is slow or partial. The significant nature and number of the remaining omissions and the provider’s failure to respond in an effective and timely way to remedy omissions that have been urgent for a considerable time temper the improvements. Care plans and records, Moving and handling, Fire training, adult protection training, appropriate notifications to CSCI, maintaining an accurate rota of staff is central to the good management of the home. Although the provider is a national company with knowledge and resources at its disposal corporate systems are not being provided to support managers to make the necessary improvements. Alphonsus House DS0000004837.V280528.R02.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 Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 25 CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 X 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X X X X X X Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standar d YA1 Regulation 4, 5 Sch 1 Requirement To produce a statement of purpose and ensure that all details are included as required by Schedule 1 of the Care Homes Regulations 2001. To produce this and a service user’s guide which should also be available in a format suitable for service users. To forward copies of completed documents to the NCSC. Not Assessed at January 2006. To make the following improvements with regard to admission procedures of new service users: 1) To ensure that written confirmation is sent to potential new service users confirming that the Home can meet assessed needs. 2) Alphonsus House Timescal e for action 31/03/0 6 2 YA2 14(1)(b & d) 12(2) 28/02/0 6 To ensure that when an Version 5.1 Page 27 DS0000004837.V280528.R02.S.doc emergency admission is made the Home undertakes to inform the service user within 48 hours of the keys aspects of the service, and all other admission criteria within working five days. Not assessed at January 2006 - no new admissions to the home. To ensure that service user contracts/statement and terms of conditions are issued to all users and contain specific information with fees to be charged, funding for holidays and all information as required by Standard 5.2. Not assessed at January 2006. To review and expand care plans to include person centred planning with long and short term goals, and all aspects of care To introduce an effective evaluation and monitoring system. To reproduce care plans in a format suitable for service users. To ensure daily reports reflect goals identified in care plans. 5 YA6 12,13,13(4) Not met at January 2006. Multidisciplinary professionals 30/04/0 6 must be consulted about: individuals who may not be able to give consent to routine / emergency healthcare and to include DS0000004837.V280528.R02.S.doc Version 5.1 Page 28 3 YA5 5(1)(B) 31/03/0 6 4 YA6 15(1) 31/03/0 6 Alphonsus House outcome in care plans; the use of ‘listening devises’ in residents bedrooms (CG). Risk assessments must be undertaken. 6 YA7 13(6) Not Met at January 2006 Consideration must be given 31/03/0 as to whether any service 6 users can manage their own financial affairs. Any service users who can must be enabled to do so with care plans in place to support this. NEW REQUIREMENT AT MAY 05 To ensure that restrictions on residents’ choices be negotiated, included in service user plans and reviewed regularly Not assessed at January 2006. To offer more opportunities for service users to participate in the day to day running of the Home through joining staff meetings, representation in management structures, recruitment and selection of staff. 7 YA8 5, Sch 3(q) 31/03/0 6 8 YA8 12(3) 31/03/0 6 9.1 YA9 Not assessed at January 2006. 13(5),13(4),13(1)(b A moving and handling risk ) assessment and care plan for JP and AB must be in place and safe practice must be implemented. All moving and handling and transfers must be included. Part met at January 2006 Copies must be provided to CSCI. 31/01/0 6 Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 29 9.2 YA9 13(4) 9.3 YA9 13(4) NEW REQUIREMENT AT MAY 2005 Risk assessments for service users with epilepsy must be developed to consider risks from TV, flickering lights etc. NEW REQUIREMENT AT MAY 2005 Not sufficiently met at January 2006. A risk assessment must be undertaken for accessing and egressing the mini bus for each service user. This must include use of the mini bus ramp. NEW REQUIREMENT AT MAY 05 28/02/0 6 28/02/0 6 9.4 YA9 13(4)(i) Not in place for service user case tracked (AD) at January 2006. To carry out detailed 31/01/0 individual risk assessments 6 with regard to: moving and handling, users who may be prone to pressure sores, users who have incontinence, epilepsy. PARTIALLY ADDRESSED AT JUNE 04. NOT MET AT June 05. Immediate Requirement issued re Moving and Handling Not fully met at January 2006. To provide training for staff in risk assessment management Not met at January 2006 to be booked by date given. Risk assessments must include the level of risk and DS0000004837.V280528.R02.S.doc Version 5.1 9.5 YA9 18(1)(c) 31/03/0 6 9.6 YA9 13(4) 28/02/0 6 Page 30 Alphonsus House the safe system employed to minimise the identified risk must contain more detail. Staff must sign all risk assessments. At January 2006 not fully met. To provide residents with accessible information with regard to the running of the Home, i.e. in the form of pictorial aids for menus, activities, service users’ questionnaires etc. Part met at January 2006 - available for activities. Care plans must be reviewed every six months and personalised to reflect the needs of the individual and needs as determined in assessments. Not met at January 2006 12 YA13 12 To ensure that service users are able to participate in community activities by providing, or arranging, appropriate transport. Not assessed at January 2006. Service users should be reimbursed for monies extracted for the holiday to taken this year. (Ongoing previous requirement referring to previous years) Not met at January 2006. Staff must use service users preferred form of address as stated in the care plan NEW REQUIREMENT AT MAY 05 DS0000004837.V280528.R02.S.doc Version 5.1 10 YA10 12(3) 31/03/0 6 11 YA13 15 Sch3(3)(q) 31/03/0 6 31/03/0 6 13 YA14 16(2)(n) 31/03/0 6 14 YA16 12 28/02/0 6 Alphonsus House Page 31 15 YA17 13(4,15,17(2),S4(1 3) Not assessed at January 2006 To seek and implement 31/01/0 professional advice in respect 6 of CG’s swallowing needs / choking risk. This advice must be requested by 28 October 2005 and must be included in a plan of care. Immediate requirement at October 21 2005. Part Met at January 2006. To review with service users (especially JS), care plans to ensure that they reflect assessed ability, needs and wishes with respect to meal preparation and detail the support required. To ensure that all staff are aware of the outcome of this review and are familiar with and implement the requirements of the care plans. To provide a copy to the Commission for Social Care Inspection That JS is made aware of the outcome of this complaint investigation and that this is confirmed in writing to the Commission for Social Care Inspection. These requirements must be met by Monday 24th October 2005. Requirements first issued following complaint investigation in September 2005. 28/02/0 6 16.1 YA17 15,12 Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 32 16.2 YA17 16(2)(i) Not assessed at January 2006 Foods required to meet service users individually assessed nutritional needs must be available New Requirement at January 2006. Aaccurate records of food and fluid intake in sufficient detail should be maintained to demonstrate an adequate daily food intake for all service users in accordance with assessed need. Jan 06 records not accurate. Safe recommended weights for each service user identified at nutritional risk must be made known to staff and recorded in plans of care – at Jan 06 safe weight not recorded but BMI recorded. Appropriate action must be planned and implemented in the event of weight loss that may threaten the health and welfare of service users at nutritional risk – at Jan 06 food included in care plans to ensure weight gain not on premises but weight gain evidenced. Where service users are at risk of losing weight which threatens their health and welfare, care plans must: a) Identify the frequency of food intake required and measures to be taken to fortify diet in a manner that accords with 24/01/0 6 16.3 YA17 17(1)(a),17(2) 29/12/0 6 Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 33 medical approval and service users wishes and preferences – at Jan 06 frequency not determined or sufficiently specific. Legal notice issued 8 December 2005. Care plans for service users who are diabetic must include hypo and hyper attacks, skin care, the potential for high blood pressure, monitoring of sick days etc. Advice must be obtained from the diabetic nurse. Not assessed at January 2006. An effective monitoring system for service users’ health care appointments and outcomes must be introduced (Good progress made at June 04) (Attention to accuracy required December 04) (Health care appointments overlooked at June 2005) Not assessed at January 2006. Staff who are witnessing the administration of medication must be appropriately trained. NEW REQUIREMENT AT MAY 05 Not met at January 2006. Medication profiles in care plans must be updated to include nutritional supplements where DS0000004837.V280528.R02.S.doc Version 5.1 17 YA19 12, 13 31/01/0 6 18 YA19 13(1)(b) 31/03/0 6 19.1 YA20 13(2) 31/03/0 6 19.2 YA20 13(2) 31/01/0 6 Alphonsus House Page 34 prescribed. NEW REQUIREMENT AT MAY 05 Not assessed at January 2006. To be assessed by the pharmacy Inspector. The medication PRN 31/01/0 guidelines (including 6 lorazapam) 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 January 2006. To be assessed by the pharmacy Inspector. To ensure care plans contain guidelines of when individual residents’ PRN, (as required) treatment, is to be administered and the frequency. 19.3 YA20 13(2) 19.4 YA20 13(2) 31/01/0 6 19.5 YA20 13(2) Not assessed at January 2006. To be assessed by the pharmacy Inspector. To provide the National Care 31/01/0 Standards Commission with a 6 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. June 05 immediate requirement issued Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 35 19.6 YA20 13(2) Not assessed at January 2006. To be assessed by the pharmacy Inspector. The policy and procedures 31/01/0 document for the safe 6 handling of medicines must be updated and amended to include the procedures identified as being absent. The secondary dispensing procedure also must be amended to comply with current practices and staff must be made aware of when it is acceptable to be used. Requirement first made by CSCI Pharmacy Inspector August 5th 2005. To be reassessed by Pharmacy Inspector 19.7 YA20 13(2) 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 Pharmacy Inspector 05/08/0 5 19.8 YA20 13(2) 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 DS0000004837.V280528.R02.S.doc Version 5.1 05/08/0 5 Alphonsus House Page 36 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 19.9 YA20 13(2) The home must ensure that every possibility is explored to make sure that the residents’ medical conditions, that require continuous treatment, are treated continuously. Immediate Requirement made by CSCI Pharmacy Inspector August 5th 2005 To be reassessed by Pharmacy Inspector 05/08/0 5 20.1 YA20 13(2) The home must investigate why the resident’s MAR chart had been signed for the administration of a Trazodone capsule when the capsule had not been administered. Requirement made by CSCI Pharmacy Inspector August 5th 2005 To be reassessed by Pharmacy Inspector 31/01/0 6 20.2 YA20 13(2) The home must obtain a clear written protocol for the administration of “when required” medication from the residents’ GP describing at what point the medication may be administered. Requirement made by CSCI Pharmacy Inspector August 5th 2005 31/01/0 6 Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 37 To be reassessed by Pharmacy Inspector 20.3 YA20 13(2) A maximum/minimum 31/01/0 thermometer must be 6 obtained and used to record the maximum and minimum temperatures of the fridge on a daily basis. Requirement made by CSCI Pharmacy Inspector August 5th 2005 To be reassessed by Pharmacy Inspector 20.4 YA20 13(2) The home must ensure that staff responsible for the administration of the residents medication undertake and complete an accredited medication handling course. Requirement made by CSCI Pharmacy Inspector August 5th 2005. Target date set was 30.9.05 To be reassessed by Pharmacy Inspector 31/01/0 6 21 YA21 12(2) To ascertain the wishes of service users with regard to terminal illness and death. These to be fully recorded on care plans. Not assessed at January 2006. The policy on ageing and illness which advocates staff discussing the benefits of will making with service users must be reviewed. Requirement made at monitoring visit on July 19 2005 31/03/0 6 22 YA21 23 31/03/0 6 Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 38 23 YA23 13(6) Not met at January 2006. The Adult Protection policy must be reviewed in line with National and Local guidelines. The reviewed policy must be dated and signed. Not met All staff must be provided with training in adult protection. 31/03/0 6 24 YA23 13(6) Not met That the provider assesses the 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 provider 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 Inspection. These Requirements made November 2005. Proposal received on December 15 2005 - at January 2006 action required. Décor damaged by fitting new windows must be made DS0000004837.V280528.R02.S.doc Version 5.1 31/03/0 6 25.1 YA24 23 31/03/0 6 Page 39 Alphonsus House 25.2 YA24 23 good e.g. 1st floor bathroom house 81. NEW REQUIREMENT AT MAY 05 Not assessed at January 2006. Action must be taken to ensure wheelchair access to bedroom, toilet, shower room for service user AD (house 81) Occupational therapy advice must be sought. NEW REQUIREMENT AT MAY 05 Not met. Unsafe slabs forming patio area at rear of house 81 must be removed and replaced to provide an even surface. To provide the National Care Standards Commission 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. Not assessed at January 2006. The manager must ensure that the Environmental Health Department is consulted about lighting levels in the premises and in respect to bedrooms where there are no ceiling lights. Not assessed at January 2006. 31/03/0 6 25.3 YA24 13(4)(C) 07/02/0 6 25.4 YA24 23(2)(a),23(2)(c) 31/03/0 6 25.5 YA26 23(2)(p), 23(5) 31/03/0 6 26 YA30 13(3) The Manager must ensure that risks of cross infection are minimised: 31/01/0 6 Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 40 Staff must not store coats and bags in the kitchen. The laundry must not be used as a storage area. 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. New Requirement at January 2006. 50 of care staff must achieve NVQ level 2 in Care by 2005. The provider must submit an action plan to the Commission for Social Care Inspection outlining how this will be achieved. NEW REQUIREMENT MAY 05 28 YA32 18(1)(a) Not met To provide up to date training for all staff commensurate with their duties in the following areas: autistic spectrum disorders, dysphagia, Data Protection Act 1998, Disability Discrimination Act 1995, vulnerable adult abuse, equal opportunities, violence and aggression, infection control, fire safety awareness, moving and handling, first aid awareness training, health and safety, basic food hygiene, accredited Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 41 27 YA32 18 31/03/0 6 31/03/0 6 medication training. 29 YA32 18(1)(a) Not met To review and update carers job descriptions to reflect goals identified in service user plans and care homes legislation. Not met To provide staff with training in diabetes awareness and Makaton. Requirement made pre December 2004 Not met 31 YA33 18(1)(a) The acting manager must differentiate her management and care hours on the rota Immediate Requirement at May 2005 - not met. 32.1 YA33 18 Not met at January 2006 Staffing hours required must be calculated using a recognised staffing tool, based upon the assessed dependency levels of each Service User. The hours required must be compared to the hours provided / budgeted for. The outcome must be provided in writing to the Commission for Social Care Inspection with an action plan to meet any discrepancy identified between the two figures. Immediate Requirement at MAY 2005, not met Not reassessed at January Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 42 31/03/0 6 30 YA32 18(1)(a) 31/03/0 6 24/01/0 6 28/02/0 6 2006. 31.2 . YA33 17(2) To ensure that an up to date 24/01/0 duty rota is maintained which 6 accurately reflects shifts covered by all staff. Enforcement Notice issued December 8 2005. Not met at January 2006, breach of Notice 31.3 YA33 17 1. To ensure that the roster is fully completed and includes all persons working at the care home to be identified by their full name Not Met 2. To ensure that the roster is a true record of whether the roster was actually worked Not met 3. To ensure Medication Records are available at all times – to be assessed by pharmacy Inspector 4. 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 Not met 5. To provide Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 43 22/12/0 5 documentary evidence to the Commission for Social care Inspection that actions 1 – 6 have been met, and a protocol to ensure that these requirements will continue to be met Not met Legal notice issued December 8 2005. Not met The frequency of staff meetings must be increased. Part met at January 2006. The rota must accurately reflect hours worked by all staff IMMEDIATE REQUIREMENT at October 2005 Legal Notice issued in December 2005 Not met, in breach of Notice The personal file of staff member P.E. must be returned to the premises and be available for inspection. Requirement made at monitoring visit July 19 2005. 32.2 YA34 19 Not met Recruitment documentation must be available for all staff Requirement made October 21st 2005. Not met at January 2006. Recruitment checks for agency staff employed in the DS0000004837.V280528.R02.S.doc Version 5.1 31.4 YA33 13(4) 12(5)(a) 18(1)(a),17(2) 31/03/0 6 24/01/0 6 31.5 YA33 32.1 YA34 19 31/03/0 6 31/03/0 6 32.3 YA34 19 31/03/0 6 Page 44 Alphonsus House home must not exceed 12 months old. Requirement first made at October 21 2005 Part Met at January 2006 – some do not contain dates of issue. When a decision is taken to employ staff on POVA first check prior to receipt of a Criminal Record Bureau check that this must be: Due to exceptional circumstance Following an individual risk assessment with control measures identified and adhered to Requirement made at October 21 2005. 33.1 YA35 18(1)(a) Part met at January 2006 To ensure that new staff are registered on a learning disability award framework (LDAF) accredited training course and that induction and foundation training for new staff is provided through a recognised LDAF trainer and assessor. Part met at January 2006. Nutrition training must be provided to all care staff and managers Requirement first made at October 21 2005. 33.3 YA35 18 Not met at January 2006. A plan with dates where 31/03/0 there are identified omissions 6 DS0000004837.V280528.R02.S.doc Version 5.1 Page 45 32.3 YA34 19 24/01/0 6 31/01/0 6 33.2 YA35 18 31/03/0 6 Alphonsus House in training, including adult protection and fire training for night staff, must be submitted to the Commission for Social Care Inspection Requirement made at October 21 2005. At January 2006 plan provided but not met. To provide accredited staff training in accordance with policy (when developed) in relation to behaviour support and physical intervention Requirement made at October 2005. Not met at January 2006 – 5 staff completed out of 23. To ensure all staff receive an annual appraisal Not met at January 2006. To ensure that all staff receive at least six recorded supervision sessions per annum. June 04 – June 05 Not met Not met at January 2006. To ensure that the Registered Manager is issued with a job description which is held at the Home for inspection. At June 2005 not met 35 YA37 37 Not met at January 2006. The Registered person must give notice in writing to the Commission for Social Care Inspection without delay of DS0000004837.V280528.R02.S.doc Version 5.1 33.3 YA35 18 31/03/0 6 33.4 YA36 18(1)(a) 30/06/0 6 01/01/0 7 33.5 YA36 18(1)(a) 34 YA37 10 31/03/0 6 24/01/0 6 Alphonsus House Page 46 the occurrence of any allegation of misconduct by the registered person or any person who works at the care home. New Requirement at January 2006. The Home must establish an effective quality assurance system that includes feedback from stakeholders in the community. Service users’ questionnaires must be completed with independent advocates. Legal Notice issued on December 8th 2005 with 3 month timescale for compliance. The registered person shall conduct a detailed audit of the quality of care provided by the home and this system shall provide for consultation with service users and their representatives. The findings shall be communicated in a report to the Commission for Social Care Inspection, together with an action plan with timescales to meet any findings identified shall be formulated. 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. 36 YA39 24 08/03/0 6 37 YA39 24 08/03/0 6 Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 47 This system and a plan for its implementation shall be communicated in writing to the Commission for Social Care Inspection. Legal notice issued December 8 2005. Timescale 3 months. Not assessed at January 2006. 38 YA40 18(1)(a) 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 January 2006. To develop policies and guidelines for staff regarding: pressure area care, ageing and death, adult protection, medication. Not fully assessed at June 2005 – not met for adult protection. 39 YA41 17(2)Sch 2 At Jan 06 not met. To obtain and hold 31/01/0 information and documents 6 in respect of persons carrying on, managing or working at a care home as listed in Schedule 2 and 4 of the Care homes Regulations 2001. Part Met at January 2006. To obtain and hold information and documents in respect of records to be kept in respect of each service user as listed in Schedule 3 of the Care DS0000004837.V280528.R02.S.doc Version 5.1 31/03/0 6 38.1 YA40 12(1)(a) 31/03/0 6 40 YA41 17(1)(a) 31/01/0 6 Alphonsus House Page 48 Homes Regulations 2001. 41.1 YA42 23(4)(d) Part met at January 2006. An audit of all staff must be undertaken to ensure that fire training is up to date for all staff, and if it is not for appropriate and timely action to be taken. Immediate at DEC 04 41.2 YA42 13 Not met at January 2006 Compliance with all recommendations/requireme nts in report of Environmental Health Officer dated 24 November 2004. NOT MET at December 2005 and January 2006 41.3 YA42 13)(4), 18(1)(a)(c) 23 The provider must ensure that all staff have received up to date fire training by a competent person An action plan with fire training dates for all staff must be supplied to the Commission for Social Care Inspection by May 13th 2005. An action plan with first aid training dates for all staff must be supplied to the Commission for Social Care Inspection by May 13th 2005. Immediate Requirement at MAY 05 Not met at January 2006. 28/02/0 6 31/01/0 6 31/01/0 6 Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 49 42 YA42 13(4), 23(2) The provider must respond in writing to the Commission for Social Care Inspection by 13 May 2005 outlining action taken and / or planned with target dates in respect of each recommendation highlighted in the three commissioned reports re Safety NEW REQUIREMENT AT MAY 04 Immediate Requirement at May 2005. Not met at January 2006. To ensure all staff receive training with regard to infection control and COSHH. June 05 not met Partially addressed at June 04 No Progress at MAY 05 Part met at January 2006 All records in respect of accidents must be retained on the premises. The manager must ensure that safe working practices are employed with respect to the moving and handling of JP. Risk assessment 31/03/06 43 YA42 18(1)(c) 13(3) 31/03/06 44 YA42 23(2), 37, 13(4)(5) 31/01/06 Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 50 must inform the care plan. Safe techniques must be included in the care plan. Transitional support for JP must be considered in the risk assessment process and care planning. A risk assessment of the bedroom identified by the Fire Service must be carried out and acted upon. All corporate risk assessments recently received must be read and signed by all staff. A general risk assessment for the building and premises must be developed and kept under review. Not Assessed 31.12.04 NOT MET 31.1.05 Not met at January 2006 Reqs re fire not assessed at January 2006. The Home must provide a business and financial plan which should be held on the premises and available for inspection. At January 2006 not met - plan available Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 51 45 YA43 25(1)(c) 31/03/06 but needs individualising and more detail. 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. Recommendation first made by CSCI Pharmacy Inspector August 2005. 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 first made by CSCI Pharmacy Inspector 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 first made by CSCI Pharmacy Inspector August 2005. 2 YA20 3 YA20 4 YA20 5 YA20 6 YA29 To ensure that radiator covers allow for easy access to DS0000004837.V280528.R02.S.doc Version 5.1 Page 52 Alphonsus House 7 YA31 8 YA38 thermostatic control 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 personnel files. To remove reference to marital status and dependents from the employee application form to ensure compliance with equal opportunity legislation. Alphonsus House DS0000004837.V280528.R02.S.doc Version 5.1 Page 53 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.V280528.R02.S.doc Version 5.1 Page 54 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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