Inspection on 20/10/06 for Alsop House

This inspection was carried out on 20th October 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alsop House 23/09/08

Alsop House 29/09/07

Alsop House 15/02/06

Alsop House 09/08/05

Alsop House 15/03/05

Alsop House 11/05/04

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOME ADULTS 18-65 Alsop House 2 Rowland Vernon Way Tipton West Midlands DY4 0RF Lead Inspector Jayne Fisher Unannounced Inspection 20th October 2006 08:50 Alsop House DS0000041325.V310439.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 Alsop House DS0000041325.V310439.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. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alsop House Address 2 Rowland Vernon Way Tipton West Midlands DY4 0RF 0121 557 2660 F/P0121 557 2660 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) Sandwell Community Caring Trust Susan Coleman Care Home 6 Category(ies) of Physical disability (6) registration, with number of places Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation reported dated: 29 September 2005 may be accommodated in the category of PD(E) This will remain until such time that the service user no longer requires the respite service. 15 February 2006 Date of last inspection Brief Description of the Service: Alsop House is a purpose built bungalow located in a residential area of Tipton. The Home provides short stay respite care for up to six adults who have physical disabilities. All referrals must be made via Sandwell Social Services as the Department has a block contract with Sandwell Community Caring Trust to fund all six beds through out the year. There is a maximum stay of three months. This is a unique service; the only provision of its kind in the borough of Sandwell. There is a small car parking area at the front of the property. The garden is situated to the rear of the property. There is level access to the front and rear of the building. The Home was registered in February 2003. There are six single bedrooms all with ensuite shower facilities. Two bedrooms have overhead tracking hoists. There is also a bathroom with an overhead hoist. There is a lounge, and open plan kitchen and dining area. The Home has a conservatory which is also used as a smoking room. A statement of purpose is available to inform residents of their entitlements. Information regarding fee levels was provided on 20 October 2006 by the manager. The current fee is £654.07 per week. There are additional charges for toiletries and hairdressing. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 8:50 a.m. and stayed until 6.00 p.m. The purpose of the inspection was to assess progress towards meeting the key national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: interviews with the manager and four members of staff. Two relatives and two residents completed comment cards prior to the inspection visit. There were five residents staying at the home on the day of the inspection. The inspector chatted to all of the residents and observed interaction between staff and residents through out the day. Two meal times were observed at breakfast and lunch; staff were also seen preparing the evening meal. Three residents’ care was case tracked by reading and assessing care documents, speaking with residents and interviewing staff. A tour of the premises was undertaken to assess the standard of the environment. Staff personnel files were accessed and a sample of maintenance and service records were examined. Other relevant documentation was reviewed prior to the visit including a pre-inspection questionnaire completed by the manager. What the service does well: The atmosphere upon arrival and through out the day was relaxed and friendly. Despite being a respite service, staff knowledge of residents was found to be detailed, and this was reflected in the positive relationships that have been formed between the staff and residents. Throughout the visit staff were seen to treat residents with respect and dignity, respecting their wishes to make decisions and encouraging choice and independence. There was lots of laughter and friendly banter between residents and staff. A range of positive comments were made by residents and relatives which are incorporated in the body of this report. The overall consensus being that staff provide such a high quality service that residents are eager to return. The inspection findings confirmed that there are many positive aspects about the service amongst which are a stable, dedicated and caring staff team who are highly trained. Meal times are relaxed and unhurried, residents can choose what food they want, and where and when to eat their meals. All personal and health care support which is given is based upon residents’ own preferences and is individualised to meet their needs. Residents are able to raise any concerns and are assured that these will be listened to and acted upon by staff. There are systems in place to protect residents from any potential abuse including good recruitment and selection procedures. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 6 There are a range of technical aids and equipment to help residents maximise their independence. The premises is bright and airy with modern furniture and furnishings. Staff are supported by a competent, experienced and approachable manager. What has improved since the last inspection? What they could do better: Record keeping needs improvement. For example, care planning and risk assessments require expansion in order to provide more written information to staff which has already been identified by the manager as needing attention. Unfortunately, the home does not have a dedicated maintenance person and a number of minor repair works and improvements have been outstanding for a while including redecoration of residents’ bedrooms. Carpets in some bedrooms remain badly stained despite regular cleaning. These were due for replacement some time ago but the manager has had difficultly in finding contractors to carry out the work. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 7 There was a serious health and safety concern identified with regard to raised An Immediate areas on the patio making this a slip and trip hazard. Requirement notice was issued for this area to be made safe within 48 hours of the inspection until appropriate repair work can be carried out. The operational manager is still not providing written reports regarding the conduct of the service following regular visits, as required by legislation. 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. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed before admission to the respite service thereby ensuring that the home can meet their needs. Prospective residents need to be provided with more information regarding the home in order to help them make an informed choice about whether or not they wish to use the service and their entitlements, if they do so. EVIDENCE: There has been an outstanding requirement for some time for the home to produce a service user guide which is representative of the service provided at Alsop House. Although there is a service user guide in place, this is a generic document for Sandwell Community Caring Trust and as such does not comply with all of the requirements of the Care Homes Regulations 2001, Regulation 5. For example, the Home does not accept self referrals as stated in this document. Accurate details must be included such, as a description of the standard services offered, the terms and conditions in respect of accommodation and personal care plus details of fees payable and arrangements for additional charges etc. It was pleasing to see that the manager is currently devising a more individualized document and stated that she is hopeful that this will completed in the couple of months. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 10 During interviews the manager demonstrated a good awareness of the principles of carrying out a thorough and holistic assessment prior to the acceptance of any new residents. Referrals are normally via a social worker and new service users are asked to visit the home first for a couple of hours in order to allow the manager and her staff carry out an assessment. This is a more effective strategy for visiting the service user within their own home as staff can then evaluate whether the equipment and aids available at Alsop House are suitable for the prospective new service user. There is a comprehensive assessment tool for gathering information about the resident and which covers all of the topics required by the National Minimum Standards 2.3. Commendably the manager is also trying to improve upon the current admission procedure to ensure that more accurate information is gained about new residents from health care specialists in order for staff to make a more informed judgement as to whether they can meet needs. A case file of a new resident who was admitted in September 2006 was examined. This contained a care plan from the placing officer which had been received prior to the resident’s admission, as is good practice. The assessment tool had also been partially completed. Staff explained that they gather information regarding service users’ needs over varying visits to the respite service. The only shortfall identified was that there was no letter to the resident confirming that the home could meet assessed needs as required by the Care Homes Regulations 2001, 14(1)(d). It was pleasing to see however that other residents’ case files did contain such a letter. It is recommended that some kind of proforma be used as a prompt to remind staff that this document needs to be provided to new service users. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All residents have a range of care plans and risk assessments in place, however some of these are more detailed than others and as a result, require review and expansion in order to ensure all aspects of residents’ support and needs are included. EVIDENCE: A sample of care plans were examined and interviews were held with staff and residents. The majority of care plans seen were basic in content but in most cases are supplemented by comprehensive and very detailed assessment tools. Given the nature of the respite service provided at Alsop House, this is a system which is possibly the most effective. However, there are a couple of areas which still need expansion and during interviews the manager acknowledges this, and states that she is hoping to improve upon current systems. For example, whilst assessment tools are holistic, key elements must be translated into care plans such as continence management. One resident’s care plan contained no details of how incontinence was managed although Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 12 there were some details in the assessment tool. This resident’s care plan regarding mobility stated that ‘X’ self propels in manual (wheelchair) – ‘staff to assist if needed’. The mobility section in the assessment tool had not been completed. Staff explained that the resident was weight bearing and used a Zimmer frame however there was no mention of this in either the care plan or assessment tool. There were no details regarding what type of transfers (such as the bath hoist, access to the mini-bus etc.), the resident needed assistance with. Another service users’ care plan was examined there were no details of pressure area care provided. Staff explained that the resident requested skin checks to be carried out at night time yet there was no mention of this in the care plan nor the pressure relieving equipment in place. Service users are generally self advocating and staff fully respect service users’ rights to make decisions. During interviews staff and management gave good examples of how they support residents in decision making, where this is required. If necessary, they will involve families and social workers if outcomes from decision making regarding how residents wish to be supported may be contentious, and is not in their best interests. It was pleasing to hear that this is always done with the resident’s consent and there is no breaching of residents’ confidentiality. As identified at previous inspections, risk assessments still require expansion as they are basic in content and in some cases do not always include all potential risks which could be experienced by residents. For example, there were no risk assessments in place for one resident who requires support to access the mini-bus using a manual wheelchair and a ramp with a winch. Two staff are involved in supporting with this transfer. Another resident’s risk assessment with regard to use of a wheelchair did not include risks associated with posture belts, seating and accessories, nor did they make reference to manufacturer’s specifications regarding use. Hazards identified in Medical Device Alert notices must be considered when establishing these risk assessments (copies of these notices were provided by the inspector at the last announced inspection in 2005). There were no details of health and safety maintenance checks, annual servicing or staff training. One resident had an accident when using the overhead hoist however a new risk assessment had not been completed alerting staff to the possible risks and the control measures in place. Residents are encouraged to undertake independent living skills tasks at the home such as making their own drinks yet no risk assessments are completed. Not all risk assessments identified who was at risk, the level of risk identified, or the safety measures already in place. One resident’s risk assessment did not contain the name or the signature of the staff member who had completed the risk assessment, neither was there a an identified date of review. These deficiencies were fully discussed with the manager including how support may be accessed to help staff improve systems. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to be participate in stimulating activities according to their individual preferences thereby enabling them to lead fulfilling lifestyles. They are able to receive visitors and therefore can maintain important family and carer links. Meals are good, offering both choice and variety. EVIDENCE: During interviews held through out the inspection all service users were extremely positive regarding the support given by staff. Comments included “I haven’t got a bad word to say”, “it’s perfect here, other homes don’t even scratch the surface” and “I like it here”. All residents who were spoken to felt that sufficient opportunities were offered to them to go on outings and trips when they wished. One resident stated “I can go out when I want, we went to the pub for Sunday lunch when I was in the last time”. Another resident stated “they will take me out whenever I want; I’ve just been out to fetch my newspaper”. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 14 Two residents completed feedback comment cards. Both stated that they could do anything that they wanted during the daytime and evening. One resident added “we can do anything within our capabilities”. All residents have a care plan in place with regard to their preferred activities. In addition there is also a daily routine sheet completed which identifies residents’ preferred routines during the day time on an hourly basis, including the leisure pursuits they like to undertake. There are regular residents’ meetings during which residents are asked to make suggestions regarding activities they would like to undertake. Minutes were examined from the last meeting held on 16 October 2006 residents had requested to go shopping and have a pub lunch. There is an outstanding recommendation to review the suitability of the home’s transport system as at present this is a mini-bus providing access via a ramp and winch. During interviews staff commented that this remains unsuitable for some residents who are unable to climb the steep steps, and for those residents who are wheelchair users, but are not able to use their electric wheelchairs to access the vehicle via the ramp as this is too dangerous. Similarly, residents with larger wheelchairs and taller headrests are not able to utilize the vehicle. As a compromise, public transport is sourced and on occasions a more suitable minibus is loaned from another care established owned by the same provider. Interviews with staff and residents confirmed that good support mechanisms remain in place to ensure that service users’ families and friends can maintain their links when the residents are on respite stay at the home. Two relatives completed comment cards and stated that they were able to visit their family members and see them in private. They both stated that staff made them feel welcome and kept them informed of important matters. Daily routines are flexible and very much tailor made to individual residents’ preferences. For example, on arrival at 08:50 a.m. only one resident had chosen to get up and was eating his breakfast in the dining area. The other three residents were still in bed and were seen to get up at varying times through out the day according to their own inclinations. One resident during interview stated that he felt staff respected his privacy and confirmed that he could have a key to his bedroom if he wished. He had keys to a lockable space within his bedroom. One resident who completed a feedback questionnaire stated “it’s definitely home from home when you come here and I look forward to my next visit”. Residents are able to choose when to be alone or when to join other residents in communal areas. One resident was seen to stay in his bedroom for most of the day and then joined the other service users for his evening meal. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 15 Interviews with residents and staff, examination of documentation and observations of meal times confirms that service users are offered a healthy and well balanced diet. One resident commented “I’m very pernickety about my food but they give me what I want”. Another resident stated “they will get me anything I want”; he confirmed that he could make his own drinks if he wished and was overhead asking a visitor if they would like a drink. There is no set menu plan as staff endeavour to provide residents with their preferred food options on an individual basis. On the day of the inspection residents were seen to have a choice of sandwiches and salad for their lunch time meal; staff had taken care to ensure that the meal was well presented. On the evening staff were seen to be preparing a steak pie, potatoes and vegetables. There are records maintained of individual residents’ chosen food options on a daily basis. These confirmed that residents can choose different meal options. As previously identified, staff need to ensure that these records are more rigorously completed. On inspection there were ample supplies of good quality fresh, frozen and dried food produce. As required at previously inspections, staff are now completing nutritional screening tools for residents. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. There are good systems in place to support residents’ personal and health care needs. The arrangements for the safe handling of medication are improving although further action is necessary in order to fully promote residents’ safety. EVIDENCE: As already stated there is a daily routine sheet completed which demonstrates what residents like to do during the day time. This includes when they would like to get up or go to bed. During interviews residents praised staff for their support. One resident commented “the crew here are fantastic; the manager is superb”. Both residents who completed comment cards stated that staff always treated them well and listened to what they had to say. There are a number of aids and adaptations to promote residents’ independence. For example there is over head tracking in two bedrooms and communal bathroom. There is also a portable hoist. Kitchen surfaces are adjustable and all bedrooms have ensuite level access showers. Since the last inspection staff now ask residents as to whether they would like to receive checks during the night time and this is recorded in their assessment tool. Some assessments contained the number of checks residents had requested and as discussed with staff, all assessments should contain this level of detail. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 17 Residents are fully supported to access health care facilities during their respite stay and on occasions this has included emergency treatment at hospital. During interviews residents confirmed that they were enabled to access specialist health care support. One resident stated “they will take me to see my doctor when I need to go”. Staff also confirmed during interviews that they would escort residents to routine hospital appointments if necessary. Case files contain medical health sections detailing residents’ specific health needs and details of any particular health conditions, as well as recording outcomes from any visits to health care practitioners. An evaluation of the safe handling of medication was carried out through inspection of records, the drugs cupboard, monitored dosage system and interviews with staff. This confirmed that improvements as required at previous inspections are receiving appropriate action. As a respite service, staff have the added difficultly of continually admitting and discharging new residents who have a range of (and sometimes complex) medication needs. In the past difficulties have arose as staff had to rely on what information residents gave them regarding dosages and quantities of medicines which sometimes did not correspond with instructions on dispensing labels. It was reassuring to hear and see new procedures which are being drawn up by the manager to eliminate discrepancies and make procedures safer by seeking clarification from the prescriber. The manager stated it is her intention to include this information in the new service user guide when this is fully completed, which is an excellent strategy. On examination there was improved record keeping with regard to completion of medication administration record (MAR) sheets. No gaps were seen or unrecognised letter codes. Staff are recording when variable doses are administered. Only one discrepancy was identified with staff hand written instructions and a dispensing label. One resident’s MAR sheet instructions stated that one Co-codamol tablet was to be given; however staff were giving one or two which corresponded with the dispensing label instructions. On the whole two staff are now involved in checking and witnessing handwritten instructions on MAR sheets when medication is received into the home. There was one occasion where a resident had received a repeat prescription during his stay but two staff had not been involved in the checking and signing of the medication. The manager arranged for staff to check this medication on the day of the inspection visit. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 18 The only new items identified at this inspection visit was with regard to the safe handling of Controlled Drugs (CD). One resident was admitted receiving Temazepam but this was not being stored as a CD. In addition the manger had purchased a CD register but this did not contain numbered pages. On examination staff are not completing this register appropriately. A separate page for each resident and each CD that they are taking must be completed. This register must also be used for the receipt, administration and disposal of all CDs with two staff signatures for every balance that is checked and carried out (including receipt, administration and disposal). Further advice and information was given. Overall it was pleasing to see the efforts made to ensure safer systems are in place. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. There is a comprehensive complaints procedure so that service users are reassured their concerns are listened to and acted upon. There are policies and procedures in place to safeguard service users from abuse. EVIDENCE: The approach employed by staff and management in dealing with complaints and making this a transparent and easy to use process for residents is commendable. Residents who were interviewed stated that they were aware who to approach if they were not happy and wished to raise concerns, although all residents added that they had never had to do so. Two residents who completed comment cards that they know how to make a complaint. Relatives who completed questionnaires also stated that they were aware of how to access the home’s complaints procedure. During interviews staff also gave good responses as to how they would support residents in making a complaint. It was refreshing to see that complaints are on the agenda at residents’ meetings when they are informed as to how to make a complaint. There have been no complaints received by the Commission regarding Alsop House during the last twelve months. The manager has received three complaints from service users (and/or their relatives) during the last year. There is a complaints log which details the investigation and outcome of complaints as required. On examination this confirmed that a full and thorough investigation had taken place into all concerns which had been raised and a letter sent to the complainant detailing the outcome within the required Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 20 timescales. None of the complaints had been upheld however actions had been taken to make improvements to ensure that systems are clarified to residents so that confusion does not arise in certain areas. There are good systems in place to protect residents from abuse. There is an on-going programme for staff who have not received training in vulnerable adult abuse. The manager stated that she had now obtained a copy of the Department of Health guidelines regarding the Protection of Vulnerable Adult (POVA) scheme as previously required. Staff who were interviewed gave good examples of how they would deal with any potential incidents of abuse. It was reassuring to hear that their main priority was ensuring that residents are safe before taking any further action. As stated at previous inspections, the home’s policy regarding vulnerable adult abuse needs expansion to include POVA guidelines including the temporary referral of staff to the POVA list when undergoing investigation. The manager states that service users are responsible for managing their own finances. Upon request however, staff will look after small amounts on behalf of residents who specifically ask them to do so. However, staff do not purchase items for residents or carry out financial transactions of their behalf. There are personal expenditure sheets for the purpose of recording any monies which are given to the home to hold on behalf of residents. It is recommended that two staff sign and check any amounts that are given to the home for safe keeping and that the same procedure is applied for any amounts returned to the service user following their stay. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 21 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. Whilst the premises continue to be homely and comfortable for residents, some refurbishment and redecoration is long overdue. The home is clean and hygienic only slight improvements are necessary with regard to managing infection control. EVIDENCE: A tour of the premises was undertaken and residents’ bedrooms viewed with their consent. During interviews residents expressed satisfaction with the facilities with the exception of two areas: carpeting and the garden/patio area. There is no doubt that Alsop House has been built to a high specification in order to meet the needs of people with physical disabilities however the replacement of stained carpets has now been outstanding for over twelve months. It was noted in 2004 that carpets had become stained and although the manager has had these professionally cleaned last year, the heavy staining and marks remain in three bedrooms. It was decided to replace these carpets however the manager has been unable to secure the services of suitable Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 22 contractors as demonstrated on the day of the inspection. Bedrooms also require redecoration as paintwork has become damaged by wheelchairs and other equipment as noted at the inspection in March 2005. This has yet to be carried out. On inspection of the maintenance and repairs book a number of minor items had been included which had been carried over from previous months. Unfortunately, according to the manager there is no dedicated handyperson responsible for carrying out such repair work as the home has to ‘share’ a maintenance person with all of the other services own by the Trust. As a result there is slow progress towards repair work. For example, the lounge door was found to be wedged open; upon discussion with the staff it was identified that the Dorguard had been broken for the past two months. Communal areas were seen to be better decorated and furnished. bright, airy and well ventilated. They are There was a serious concern identified at this inspection which required immediate action to be taken to ensure the health and safety of service users, staff and visitors. The patio area is generally uneven with raised slabs. However, there were 3 perilously raised manhole covers surrounded by broken slabs which constituted a slip and trip hazard. Action was required to be undertaken with 48 hours to make these areas safe until the necessary repair work could be carried out. All parts of the home were seen to be hygienic, clean and tidy. The laundry contained information relating to the control of hazardous substances (COSHH) as previously required, laundry procedures were on display, flooring and walls are impermeable. There are laundry sacks in place to transport dirty laundry through the premises and there is an industrial washing machine with a sluice. There are a couple of minor improvements required as detailed in the Requirements section of this report. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 23 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, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a stable, experienced and competent staff team. Recruitment and selection procedures for new staff offer protection for residents. EVIDENCE: During interviews staff demonstrated a commitment to their job roles and a good understanding of the needs of the service user group. Information provided by the manager confirms that all 7 staff have either undertaken an NVQ II or III which exceeds the national minimum standards. Training files sampled contained evidence of certificates. Other specialist training has been provided including epilepsy awareness, diabetes awareness and sexual awareness. One member of staff whose file was sampled also had certificates for training in bereavement, autism and incontinence. All staff who were interviewed stated that training is fully promoted and they could think of no further training from which they would benefit. The home has a full complement of staff and any shortfalls due to sickness or annual leave is covered by bank staff employed by the Trust. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 24 Examination of the duty rota confirms that there are two or three staff on duty during the day time; there is one waking and one sleeping in member of staff. There were a couple of negative comments made by relatives and staff with regard to staffing levels. The manager admits that during the past few months the home has had periods of full occupancy and that the service as a whole is now getting busier. As a result the manager has not always been supernumerary and has been covering some shifts as a support worker. However, this situation has now been rectified by the use of ‘surplus’ hours which are already allocated to the home, and as a result there is now a third member of staff on duty during the morning period. The manager states that she feels this will now enable her to spend more time on her managerial responsibilities although she does routinely cover shifts to supervise and support her staff. The duty rota must indicate what hours are supernumerary and which hours are support work as discussed. There are regular staff meetings the last one taking place on 19 October 2006. A good range of topics are discussed. A personnel file of a new member of staff was examined to evaluate recruitment and selection procedures. This new member of staff is currently being inducted by the manager with a view to working elsewhere in the Trust, and therefore will not be a permanent member of staff at the home, which as already stated has a full complement of staff. Good procedures are in place with a range of pre-employment checks undertaken and forms of identification held on the file as required. There are only a couple of minor items which would further enhance current systems in place. For example, the Trust uses a proforma for referees to compete, however there is no confirmation as to date when the reference is completed by the referee, or received by the Trust. This must be included to demonstrate that references are received prior to commencement of duties. The new member of staff had provided an employment history of three previous employers. However it was seen that a reference was obtained from a fourth previous employer who was not included in the employment history by the applicant. This needs to be clarified in line with the Care Homes Regulations 2001. Training records and associated documentation was seen to be very well organised which made auditing easy. There is no training and development plan as this is held centrally at the organisation’s headquarters. The manager however during interviews clearly knew the training needs of her staff team and also organises some training herself. There were up to date individual training profiles for each member of staff which correlated with training certificates which were sampled. There were no major shortfalls in training seen, and therefore the requirement to establish a training and development plan has been withdrawn as current systems are efficient. The requirement to provide staff with structured induction and foundation training has also been withdrawn and will be evaluated upon a new permanent member of staff being appointed to Alsop House. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 25 Supervision records were accessed. There is evidence of formal supervision of staff. Some staff have received more frequent supervision than others, and as previously identified, all staff must received at least six supervision sessions per annum. For example, one member of staff had only received 3 supervision sessions during 2006 (which included an annual appraisal). It was pleasing to seen that staff files contained evidence of annual appraisals being carried out. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 26 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 good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and competent and provides clear leadership; as a result service users benefit from a well run home. As far as is reasonably practicable, the health, safety and welfare of service users continues to be well promoted and protected. EVIDENCE: Observations and interviews with staff and service users confirm that Mrs. Coleman remains committed to the service and is an attentive and approachable manager. During interviews staff confirmed that they would always go to the manager if they were in doubt about anything. There are good strategies in place for cascading information to staff including regular meetings and supervision sessions. In addition Mrs. Coleman has elected to work one evening a week so that she can support night staff and continue to assess the needs of the service user group during this period which is an Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 27 excellent initiative. Despite the respite service becoming more popular Mrs. Coleman was able to demonstrate that she is continuing to work towards meeting the outstanding requirements made at previous inspections and is committed to raising standards of what is already a high quality service. Mrs. Coleman has recently enrolled on the Registered Manager’s award in order to complete the required qualification of an NVQ IV in care by 31 September 2007. She also keeps herself up to date with changing legislation by attending relevant statutory training, reading relevant guidance and best practice, and by attending briefing days arranged by CSCI. As previously identified quality assurance systems need expansion. There is regular consultation with residents about the service. This used to take place after every admission but in order to encourage more participation from residents has been reduced to once a year. Other quality assurance systems involve checks carried out by all line managers on either a weekly, monthly and quarterly basis. However, an annual development plan needs to be established based upon a systematic cycle of planning-action-review. The quality assurance system also must include feedback from relatives, stakeholders and other third parties. Staff personnel files continue to be held at the provider’s head office and as a result information required by the Care Homes Regulations 2001 are not held on the premises. New guidance was issued by CSCI in November 2005 with regard to storage and retention of CRBs and other information required by the Care Homes Regulations 2001, Schedule 4. The provider needs to decide whether this is relevant to the organisation and make an application for a formal agreement with CSCI to retain documents at their head office. Subject to written agreement with CSCI certain documents can then be kept within a provider’s centralized Human Resources department. The CSCI has also devised proformas upon which providers can record the information required. A random sample of maintenance and service checks were examined. These were found to be up to date and outstanding requirements therefore have been met in a number of areas. For example there is more regular testing of the emergency lighting system, staff are participating in at least bi-annual fire evacuation drills and risk assessments have been carried out for COSHH substances. Other examples of good health and safety practice included weekly testing of the fire alarm system, annual servicing of fire maintenance equipment, inspection of all lifting equipment, annual testing of portable appliances and regular testing and recording of water temperatures. Training certificates sampled indicates that statutory training has been undertaken by the majority of staff in all the required disciplines including fire safety which was undertaken by most staff in May 2006 and a further training is planned in the near future. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 28 The fire officer visited in May 2006 and has now approved the fire exits including the arrangements for exiting the manager’s office. A requirement to update the fire risk assessment (as identified at previous inspections), is receiving action by the manager who has obtained a suitable profroma to carry out this assessment. Food hygiene was seen to be good and in particular all fridge, freezer and cooked food temperatures are now more consistently checked and recorded. The service provider is still failing to comply with the Requirements of the Care Homes Regulations 2001, Regulation 26. Although a senior manager from the organisation is visiting on a regular basis, a written report of the conduct of the home is neither provided to the manager or the Commission for Social Care Inspection. The last report held on the premises was dated February 2006 and the last report sent to CSCI was dated January 2006. This must be addressed. Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 29 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 2 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 4 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 4 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 30 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 6 Requirement To amend the Service User Guide, to include all of the information as required by the National Minimum Standards (NMS) for Younger People Standard 1.2. i.e. details of experience and qualifications of staff etc. To forward a copy of the completed document to the CSCI. (Previous timescale of 1/12/03 is partly met). To ensure that care plans cover in sufficient detail all aspects of personal, social and healthcare needs, for example with regard to pressure area care or nutrition. (Previous timescale of 1/10/05 is partly met). To carry out individual written risk assessments with regard to all aspects of care including: service users who self medicate, wheelchair users, service DS0000041325.V310439.R01.S.doc Timescale for action 01/01/07 2. YA6 15 01/01/07 3. YA9 13(4)(c) 01/01/07 Alsop House Version 5.2 Page 31 users undertaking activities in the kitchen, pressure area care. (Previous timescale of 1/10/03 is partly met). To expand risk assessments to include the level of risk identified and include the actual date of review. (Previous timescale of 1/7/04 is partly met). To review and update risk assessment with regard to use of the mini-bus ramp and new hoist/seat belt. (Previous timescale of 1/11/05 is not met). 4. YA17 16(2)(i)12(1)(a) To ensure more consistent recording of service users chosen options from the daily menu. (Previous timescale of 1/11/05 is not met). 13(2) 1) To review and amend the medication policy to ensure it accurately reflects procedures at Alsop House. (Previous timescale of 1/11/03 is not met). 2) To ensure that all staff responsible for the administration of medication sign the administration of medication procedures. (Previous timescale of 1/11/03 is not met). 3) To organise accredited medication training for all staff in the safe handling of medication. (Previous timescale of 23/12/03 is partly met). Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 32 01/01/07 5. YA20 01/01/07 4) To obtain written consent to administration of medication from service users who require staff to administer their medication with records held in individual care plans. (Previous timescale of 01/06/06 is not met). 5) To introduce a signature sheet for the handover of medication keys. (Previous timescale of 01/06/06 is not met). 6) To improve systems for recording receipt of medication into the home and handwritten instructions on Medication Administration Record (MAR) sheets - to obtain two staff initials to confirm correct instructions have been recorded with regard to administration and dosages. (Previous timescale of 1/06/06 is not fully met). 7) To improve risk assessments to establish if service users are able to self administer medication (for example through competency tools). (Previous timescale of 1/6/06 is not met). 8) To ensure that where instructions on dispensing labels differ from instructions given by service users and/or their relatives with regard to dosages, that their written signatures are Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 33 obtained to confirm that the information they have given is correct (or to seek clarification with the prescriber). (Previous timescale of 1/6/06 is partly met). 6. YA23 13(6) To provide all staff with training in vulnerable adult abuse. (Previous timescale of 1/2/03 is partly met). To expand the vulnerable adult abuse policy to include the new procedures on the Protection of Vulnerable Adult (POVA) scheme. (Previous timescale of 1/12/05 is not met). 01/02/07 7. YA24 23(2)(b) To make the following improvements to the environment: 1) To clean (or replace) all stained carpets in communal and bedroom areas. (Previous timescale of 1/3/04 is partly met). 2) To ensure that bedrooms which have been fitted with French patio doors have suitable window ventilation. (Previous timescale of 1/3/04 is not met). 3) To carry redecoration of bedrooms were paintwork has become damaged and worn. (Previous timescale of 1/7/05 is not met). 01/01/07 Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 34 4) To make safe the areas surrounding the 3 raised manhole covers and broken slabs on the patio area within 48 hours of the inspection and to confirm in writing to CSCI what action has been taken. IMMEDIATE REQUIREMENT BY 22/10/06 To forward written proposals together with timescales for completion to CSCI regarding the repairs to the patio to make this a safe and level area within 28 days of the inspection (by 18 November 2006). 5) To repair the broken Dorguard fitted to the lounge door. 8. YA30 13(3) To make the following improvements to infection control: 1) To display risk assessment with regard to manual sluicing of soiled items in the laundry. (Previous timescale of 1/3/04 is not met). 2) To ensure that there is a supply of liquid soap in all communal bathrooms, toilets and the laundry area. 3) To cease using communal items and remove them from bathrooms and toilets such as nailbrushes and a plastic jug. 01/01/07 Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 35 9. YA33 17(2) 8. YA34 19(1)(b) 10. YA36 18(2)(a) To ensure that the duty rota 01/01/07 identifies the supernumerary hours worked by the manager and those which are worked as care hours. To ensure that a written 01/02/07 explanation is obtained for any discrepancies with regard to former employment histories given by new staff, (on their application form), which do not correlate with details provided by their referees (A full and accurate employment history must be obtained prior to commencement of duties). To ensure staff receive a 01/02/07 minimum of six recorded supervision sessions per annum. (Previous timescale of 01/12/05 is not fully met). To develop an effective quality assurance system to include feedback from service users’ relatives, stakeholders in the community: district nurses and general practitioners etc. An annual development plan must be established based on a systematic cycle of planning-action-review. (Previous timescale of 1/5/04 is not met). 01/02/07 11. YA39 24 12. YA41 17(2)19(1)(b) To obtain and hold information and documents 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 01/02/07 Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 36 2001 (or to make a formal request to CSCI to retain documents at head office and obtain approval using new guidance and documentation issued in November 2005). (Previous timescale of 1/9/03 is not met). 13. YA42 13(4)(a)23(4) To make the following improvements to fire, and health and safety: 1) To review and update the fire safety risk assessment in view of recent changes to the premises in respect of fire safety precautions (Dorguards etc). (Previous timescale of 1/6/05 is not met). 14. YA42 16(2)(j) To make the following improvements to food hygiene practice: 1) To provide a separate hand washing facility in the kitchen area. (Previous timescale of 1/5/04 is not met). 15. YA43 25, 26 To ensure that there is a written report on the conduct of the home completed by the providers representative who is carrying out monthly visits. A copy must be provided to the Registered Manager and a copy forwarded to the Commission for Social Care Inspection. (Previous timescale of 1/12/05 is not met). 01/01/07 01/02/07 01/02/07 Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 37 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA2 YA13 YA20 Good Practice Recommendations To devise a proforma/prompt to remind staff to write to prospective new service users confirming that they can meet needs. To consider the purchase of a more suitable or second vehicle in order to accommodate all wheelchair users. To treat Temazepam as a Schedule 2 Controlled Drug (CD) with regard to storage and administration. To purchase a more appropriate Controlled Drugs Register that should be a bound book with numbered pages. To improve safe handling and recording with regard to Controlled Drugs: to ensure that the CD register is used to record the receipt, administration and disposal of CDs, a witness should sign to verify the balance is correct each time and, each drug for each patient, should be recorded on a separate page. To ensure that where monies are given to the home for safekeeping, that two staff witness and check the balance upon admission and upon discharge, with two staff signatures on personal expenditure sheets to confirm that this has been carried out. For the registered provider to consider appointing a maintenance person solely dedicated to carry out repairs work at the home, or to allocate a number of dedicated hours per week. To ensure that either the date of the referee completing the reference is recorded, or the date upon which the reference is returned to the service provider. 4. YA23 5. YA24 6. YA34 Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alsop House DS0000041325.V310439.R01.S.doc Version 5.2 Page 39 - 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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