Inspection on 23/09/08 for Alsop House

This inspection was carried out on 23rd September 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alsop House 29/09/07

Alsop House 20/10/06

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 22/11/2008.

CARE HOME ADULTS 18-65 Alsop House 2 Rowland Vernon Way Tipton West Midlands DY4 0RF Lead Inspector Sally Seel Key Unannounced Inspection 23rd September 2008 09:00 Alsop House DS0000041325.V371945.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.V371945.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.V371945.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 0121 557 2660 alsop@sandwellcct.org.uk 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.V371945.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. 27 September 2007 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. 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 that is also used as a smoking room. Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes’ capacity to meet regulatory requirements, minimum standards of practice and on aspects of service provision that need further development. One inspector undertook this fieldwork visit to the home, over an nine hour period. The registered manager and staff members assisted us throughout. The home did not know that we were visiting on that day. There were six people living at the home on the day of the visit and the inspector arrived before people living in the home had left for the day. Information was gathered from speaking to and observing people who lived at the home. Three people were “case tracked” and this involved discovering their experiences of living at the home. This was achieved by meeting people or observing them, looking at medication and care records and reviewing areas of the home relevant to these people, in order to focus upon outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files, training records and health and safety records were also reviewed. Prior to the inspection the registered manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave us some information about the home, staff and people who live there, improvements and plans for further improvements, which was taken into consideration. Regulation 37 notifications about accidents and incidents in the home were reviewed in the planning of this visit. Also surveys were sent out to people who use the service and one survey was completed and returned to the Commission for Social Care Inspection, (CSCI). Information from all of these sources was used when forming judgements on the quality of service provided at the home. The people who experience respite stay at this home have a variety of needs. We took this into consideration when case tracking three individuals care provided at the home. For example, the people chosen consisted of both male and female and have differing communication and care needs. The atmosphere within the home is inviting and warm and we would like to thank everyone for their assistance and co-operation. What the service does well: Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 6 Prior to peoples respite stay at the home they are encouraged to visit the home which gives people the opportunity of being part of their pre-admission assessment and they can be then reassured that the home will meet their needs. Peoples social care needs are documented which provide the staff with knowledge around a person’s emotional and psychological wellbeing. This is important in promoting peoples aspirations and ultimate goals. Flexibility, choice and independence are promoted in relation to people’s daily life. This is particularly around choosing when and where to eat and those people who are able to cook their own meals are actively encouraged to do this. People are supported in a respectful manner by staff working at the home and this ensures that people’s dignity and self-esteem are maintained. One person shared with us that the staff see the person and not their disability. People feel that staff do actively listen to them when making a complaint and /or sharing their concerns with staff at the home. This means that the home promotes peoples rights to have their views heard and acted upon. The home is clean, tidy and hygienic reinforcing the commitment to infection control for the people who use the service. There is a high level of staff who have their National Vocational Qualifications (NVQ), which is a tribute to staff being committed to succeed in wanting to gain knowledge and skills to meet peoples needs appropriately. The home maintains consistency in their staff group which benefits the people who use the service in receiving care from people who are familiar with, and have knowledge of, their personal preferences. The registered manager is striving to make improvements that meet people’s individual needs and ensure that people are part of this process. This ethos can only enhance the quality of life for people who use the service. People told us:“They (staff) see the person, not chair or disability”. “Never bored here”. “Don’t want big meal; you can have a small one”. “We can cook and make a drink”. “You can have any meal you like”. What has improved since the last inspection? Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 7 Care plans are improving in respect of showing all aspects of individuals personal, social and health care needs. This is important to ensure people’s needs are met adequately and in a way they prefer. There have been some improvements made in the area of the homes procedures and practices in respect of medication. This goes some way to safeguard people. The home has now purchased a new bus so that all people will be able to participate in trips in the community and people will not be disadvantaged because of their disabilities. There have been some improvements to the homes environment in relation to bedrooms being redecorated and a new electric manual hoist. The registered manager has told us that further improvements are going to be made to other areas around the home to ensure the home remains comfortable, safe and promotes peoples independence. The registered manager has now developed a system for recording accidents to enable these to be tracked, monitored and any trends focused upon to ensure people are protected from any preventable injuries and/or harm. Staff have now undergone fire training and the registered manager has now devised a system whereby individual staff members are responsible for certain health and safety checks, such as, fire drills and alarm tests. This will safeguard people from any health and safety risks. What they could do better: Peoples changing needs require reviewing regularly to ensure that risk plans and assessments are in place to minimise any risks to individuals and to safeguard people. Further improvements need to be made in relation to the handling and giving of people’s medication. This is particularly in reference to the staff emptying people’s medication onto side trays/tables for people to take. This is to ensure that no errors are made and medication is given to diminish any potential infection risks to people. The improvements to the homes environment need to continue and CSCI should be made aware of when the three bathroom floors have been repaired. Also consideration needs to be made in relation to security gates being erected on the homes car park area. This is due to children seen throwing bricks and other items in the car park and running around this area of the property at the last inspection of the home. These improvements will ensure that people’s choice, independence and safety can be maintained. Staff members mandatory training needs to be analysed and a format developed for this to be monitored thus ensuring that refresher courses are Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 8 provided to staff before their original certificates expire. This will provide confidence to people that the care they receive appropriately meets their needs with health, safety and welfare risks minimised. The homes documentation in relation to recruitment records needs to be more robust to ensure all the required recruitment checks have been made and these can be evidenced within staff member’s records. This will ensure that vulnerable people are protected. Recruitment records are maintained at the services central head office. This issue has been discussed previously with the registered provider and a requirement made relating to this. The provider needs to make a written 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. This then would be stored at the home and used to evidence that the homes/organisations recruitment procedures safeguard people. There is a list of requirements and recommendations at the end of the report should the reader wish to look at these. 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.V371945.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have sufficient information about the home to enable them to make an informed decision about whether they would like to have their respite stay in the home. Pre-admission assessments are undertaken by people visiting the home to ensure that people know their needs can be met prior to their respite stay. EVIDENCE: The home is unique in that it provides people with the opportunity of respite care. This means that people live in the home for short periods of time. The home has produced a Statement of Purpose and service user guide. These tell people what services are on offer to them and how their individual needs can be met if they choose to have respite stays in the home. Also the registered manager told us in her completed, Annual Quality Assurance Assessment, (AQAA), ‘all service users are assessed on the unit so all parties are aware of what the service, building and company are about’. People are given the opportunity of looking around the home, meeting members of staff and assessing equipment on an individual needs basis. This results in people having the information they need about the home, and that the home is able to meet their specific needs before they choose to have their respite stay. Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 11 We looked at three peoples care plans and saw written confirmation that residents receive a copy of the statement of purpose and service user guide. People have been made aware of the contents of care plans and have been given a copy of their contract of residency. This means that people’s needs are considered and plans on how to meet these are drawn up prior to individuals respite stays in the home. However, evidence gathered during the inspection indicates that further work is now required in respect of risk assessments for people who require some physical assistance particularly where slings and hoists are used (see sections relating to care planning). People told us:“Home is very nice”. “Staff are very friendly”. “All staff are caring”. Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can be confident that care plans do reflect their current care needs but risk assessments need to be regularly reviewed to meet changing needs. People are supported to participate in all aspects of their lives which include planning the care they receive in the home and how those needs are met. EVIDENCE: The home has made good progress to ensure all care plans cover all aspects of people’s personal, social and health care needs. Evidence was gained from examining peoples care records. People’s social, emotional and psychological needs are documented for staff to follow through in a sensitive way. For example, informing staff to support people who have difficulties in expressing their own emotions when conversing. The plan informed staff not to stop conversing with people but to encourage people to participate. This shows good understanding and knowledge of a persons needs as a whole to enable individuals to have the confidence that they will be supported through difficulties and goals for people can be achieved. Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 13 In one persons care records there was no evidence of a risk assessment being completed in respect of this persons changing physical abilities. Observations on the day of our visit informed us that this person now required hoisting with two members of staff. This would suggest that the home needs to undertake further work in recording peoples individual needs particularly if these change. Consistency is now required with regards to staff drawing up plans and risk assessments to meet peoples changing needs, making sure that these are reviewed regularly. The registered manager was made aware of the persons risk assessment not detailing the instructions for staff using a hoist and this was rectified immediately. Without these instructions in place people cannot be confident that the home will effectively manage peoples changing needs so that risks will be reduced thereby offering people sufficient protection from harm and/or injuries. The registered manager explained to us that people’s needs are looked at before they come for respite care at Alsop House and if people need bed rails then rail protectors would be in place. If the home did not have any rail protectors due to them not being available at that time then the home clearly would not be able to meet that person’s specific need. If the person’s choice is not to have rail protectors then this should be clearly documented. This practice will make sure that the home has sufficient safeguards in place for people’s protection. From observations on the day of our visit people are included in planning the care that meets their needs and making decisions about how needs are met. For example, people gathered around the kitchen table when they were ready to have their breakfasts. Breakfast was provided when each individual person arrived at the table and staff were sensitive to each individual persons needs, asking what the person wanted to eat and drink. Also when staff members were going to clean a person’s room they would announce this fact to each person thereby valuing people’s choices and privacy. Meetings are held whereby people who are having their respite stay in the home are invited to speak about what likes and/or dislikes they have about the care and support people receive in the home. There is also an opportunity to state what suggestions they have for the home to improve. The registered manager then looks at what action would be taken on some of the points raised in these meetings. People who were spoken with on the day of our inspection seemed to feel that these meetings were a good way of having their likes and dislikes heard. People seemed to value the registered manager’s involvement in these meetings. For example, people stated that the registered manager did really listen to individuals and try to meet people’s needs to give people choices around the care that they received in the home. In the completed AQAA the registered manager stated, ‘To continue providing care to individuals ensuring service users participation’. This reflects a commitment to consulting people in all aspects of life in the home. Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 14 People told us:“Feel normal, grown up here”. “Talk about problems to people, they are like a second family”. “We can do anything we like”. Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are encouraged to choose the activities that they participate in which is a reflection of peoples individuality and independence. People are able to flexibly choose their own meals and where able people’s independence to actively cook their own meals is celebrated EVIDENCE: We saw staff talking with people who live in the home throughout the inspection politely and in a friendly manner. The home was seen to promote peoples daily routines in a flexible manner. For example, people were moving around the home freely, choosing where to sit, what they wished to do and who to interact with. On arrival some people were having their breakfast and others were just rising to begin their day. Throughout the day people were seen to be choosing their preferences on how to spend their day. One person wanted to watch their favourite television programme in their room without any interruptions and this was respected by staff. Another person was Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 16 observed to be cleaning their room, therefore gaining a sense of independence and valuable life skills. Also people were seen preparing their own drinks and meals at times they preferred so that peoples independence is promoted. People shared with us on the day of our visit the activities individuals enjoyed participating in whilst they were having their respite stay at the home. People said there was bingo, listening to music and going out shopping. The home also have a cat, ‘Oliver’, who people spoke fondly of on the day of our inspection who has become part of daily life in the home and people seem to get a lot of enjoyment from ‘Oliver’. Peoples faces generally ‘lit up’ when describing ‘Oliver’ to us on the day of our inspection which shows that peoples wellbeing is promoted by the homes approach to having ‘Oliver’. The home has now purchased a new bus to ensure that people are supported in their choices to spend days out in the community as a group. The homes new transport means that people with physical difficulties who have large wheelchairs will be able to go in the homes new bus thereby not restricting peoples wishes. On the day of our visit breakfast and lunchtime meals were observed. People were seen to have their meals at the times of individual choices and were provided with individual meal preferences. Therefore menus are not always used as meals are provided in a flexible way with what people want on any given day. People were relaxed and seemed to enjoy gathering around the kitchen table to eat their meals and engage in conversation with others. Staff also had meals and drinks with people where conversation was encouraged. One person had some difficulty in eating their meal but staff were seen to be patient and did not hurry this person but were sensitive to their needs. One person wanted an alternative drink and this was provided without any fuss being made. Peoples own specific food options and/or cultural needs were observed at all times. The registered manager explained how the home does purchase some foods that meet people’s cultural needs but even then people are given the choice to ensure that people are not discriminated against. People spoken with on the day of our visit confirmed that visitors are made very welcome by the home and visiting was not restricted in any way. People told us that husbands, grandsons, daughters and friends come to visit people when they are having their respite stays. People told us:“They (staff) see the person, not chair or disability”. “Never bored here”. “Don’t want big meal; you can have a small one”. “We can cook and make a drink”. “You can have any meal you like”. Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that systems are continuing to improve in relation to the home promoting peoples health and social care needs adequately. The management of medication ensures that people receive their medication as prescribed but further minor improvement needs to be made when staff handle and give medication to people. EVIDENCE: Everyone who lives in the home has access to the health care they need. People’s care plans show that people are seen by their doctors when they are ill and by other health care professionals when needed. Care records that were sampled had good information in respect of peoples social and health needs. For example, good outline of people’s medical condition with medication prescribed to each individual. There are additional sheets where individual development plans are recorded together with monthly records of achieving goals and separate information sheets in respect of external professionals, such as, dentists, community nurses, doctors and opticians. This is important due to the respite service that is provided to people. One person described how their finger got caught in the door and how staff reacted with appropriate Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 18 action. This person said she felt reassured by staff’s reaction at the time and therefore this shows that the home are promoting peoples health and social care needs appropriately. The home has a locked cabinet in the office area where medication is stored. However, this needs to be looked at as difficulties do arise due to staff having to take the ‘tot’, (small container), of medication to each individual person from the cabinet in the office area. The home has no medication trolley for this purpose. Staff also have to come back to the office to record that medication has been given and people have taken this. We observed people having their morning medication and staff were seen emptying people’s medication from the ‘tot’ onto side trays/tables. The registered manager will now look at how medication is given to people to make sure that it is done in a hygienic way and thereby any risk of infections to people are minimised. The registered manager confirmed that the temperature is now monitored to ensure people’s medication is stored as per manufacturer’s guidelines. People are supported to take their own medication wherever possible and two people told us that they were self medicating. People told us:“Talk about problems, like a second family here”. “Staff understand what my health is like”. Alsop House DS0000041325.V371945.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is comprehensive and is accessible to people should they need to make a complaint. There are systems in place to ensure people are safeguarded and protected. EVIDENCE: There have been no complaints received by CSCI during the last twelve months. The home has a procedure in place for looking at any complaints that it receives. All complaints and/or concerns are fully investigated and an outcome sent to the complainant within the required timescales detailing any outcomes. The home also displays its complaints procedure at the entrance to the home. Staff members were able to state where the complaints book is for documenting any complaints and how the process works for making a complaint together with following this through to a satisfactory conclusion. This homes complaint procedure is comprehensively documented in their statement of purpose/service user guide and within peoples case records sampled there was evidence that a copy had been given to people. Generally people spoken with knew how to make a complaint and/or raise a concern if they needed to. People said they could do this individually to the registered manager or if they chose people could raise it in their ‘client meetings’. People seemed to feel that the registered manager listened to any complaints and/or concerns that they had. The home is looking at ways of enhancing the process of feedback they receive from people who use the Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 20 service. For example, the registered manager within her completed AQAA has stated: - ‘To collate questionnaires and send out feedback to show how we listen and act upon what people say’. This provides the evidence that the home promotes peoples rights to have their views listened to and how these are acted upon in a timely fashion. There are good systems in place to protect people from abuse. Staff spoken with had a good understanding of the action needed to report any abuse they witness and/or allegations that should be made to them. There is an on-going programme for staff who have not received training in vulnerable adult abuse. There is a copy of the Department of Health guidelines regarding the Protection of Vulnerable Adult (POVA). This provides confidence to people that they will be protected from abuse whilst experiencing their respite stay at the home. People have lockable facilities in their rooms where they can keep their own monies and/or other valuables. One person told the inspector about this facility. However, upon request staff will look after small amounts of monies on behalf of people who specifically ask them to do so. There are personal expenditure sheets for the purpose of recording any monies which are given to the home to hold on behalf of residents. On the day of our visit the home was keeping one person’s monies, this was checked and monies stored were correct. Generally people are encouraged to safeguard their own monies where appropriate. People spoken to confirm there are lockable facilities in their rooms and these are working. People told us:“We go to see X (the registered manager)”. “I have no complaints but would see the manager if I had”. Alsop House DS0000041325.V371945.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally people are provided with a homely, clean and comfortable environment. There have been some improvements made to the homes environment but further work is required to maintain people’s independence and safety. EVIDENCE: The home is kept clean, hygienic and tidy and provides a homely and welcoming environment to live in. The rooms of the people whose care was case tracked showed that these were satisfactorily cleaned and well presented. Each room had en-suite facilities. The home has made some improvements to its environment for people since their last inspection. For example, bedrooms have been redecorated and a new electrical manual hoist had been purchased. This is a good start and shows the commitment of the registered manager in wanting to provide a comfortable Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 22 and safe environment for people. However, three bathrooms require attention to the flooring where this appears to have come away allowing water to run underneath. The registered manager told us that she is in the process of this work being undertaken and will let CSCI know once the work has been completed. However, the recommendation in respect of the home fitting security gates will still need to be considered and therefore remains a recommendation. This is due to the incidents on the day of the homes last inspection whereby children were seen throwing bricks and other items in the car park and running around this area of the property. On seeking the views of some staff members it was thought that the gates would at least be some form of deterrent as effort to climb them will need to be made by the children. Staff stated that the incidents from children are worse in the school holiday periods. The registered manager has been to the local housing office and spoken with the local police but no relevant action has been taken by either parties. Therefore the home need to strongly consider fitting security gates as this will provide further security and safeguards to visitors, staff and people who stay in the home for respite. The home does have a ‘handyman’ and this person undertakes maintenance work around the home but the staff have to contact this person when work requires completing. However, the staff spoken with do not feel that this is an issue as the handyman does always come when asked to. At the time of our visit there was no evidence of work outstanding in respect of small repairs around the home which would affect people’s choices and/or quality of life whilst living in the home other than the repairs needed as detailed in this report. The registered manager informed us that the mops are now being washed in the machine at the required temperature to promote good practice and infection control. There has been some feedback from one person in the home who finds the lounge chairs too low for them to sit on and this has now been brought to the attention of the registered manager who will look into this issue. There are a variety of chairs for people to sit on within the lounge area which is an example of the service trying to meet people’s individual physical needs which can be difficult in a respite situation. People in general liked the décor of the home and one person said “It is lovely and very clean”. Alsop House DS0000041325.V371945.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally staff are well trained and have the skills and knowledge to meet peoples individual needs. There now needs to be a more robust system in place in relation to refresher courses for all mandatory training. The homes recruitment procedure needs to be accessible with all documentation in place to ensure vulnerable people are protected. EVIDENCE: There is a full complement of staff. The home maintains a stable staff group as no staff have left for over a year. Any shortfalls due to sickness or annual leave are covered by bank staff employed by the Trust. Discussions with staff and examination of rotas demonstrate that between two and three staff are on duty during the morning and afternoon. There is a waking member of staff and sleep-in person during the night. In addition to this the manager undertakes the majority of her hour’s supernumerary to care. There are regular staff meetings where a good range of topics are discussed. Staff demonstrated a commitment to their job roles and a good understanding of the needs of people. This was further reinforced when one staff member Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 24 completed the outstanding risk assessment of a person being hoisted when the inspector requested this. It was done clearly and concisely with instructions documented in step form to enable other members of staff to follow these to ensure the correct procedure to meet this persons needs would be met safely. The homes recruitment records are maintained at the services central head office. However, the registered manager collected these to enable us to examine a sample of staffing records. This issue has been discussed previously with the registered provider and a recommendation made relating to this. The provider needs to 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. This then would be stored at the home and used to evidence that the homes/organisations recruitment procedures safeguard residents. A sample of staffing records was examined and one of these did not have a completed application form and two references stored on it. A requirement has been made for the home to look into this matter and provide CSCI with an outcome. This will make sure that people are supported and protected by the homes recruitment policy and practices. The registered manager told us that 90 of staff have National Vocational Qualification, (NVQ), Level 2. This exceeds the recommended level. Seven staff have NVQ Level 3 with two staff undertaking this and there are two members of staff with NVQ Level 4. The home did not have a training matrix on the day of our visit and therefore we could only examine a sample of staff members training records. These showed that staff member’s mandatory training was generally up to date. However, there is a potential for refresher courses in mandatory training to be overlooked and for staff to not receive refresher courses once their certificates have expired. This was pointed out to the registered manager to ensure staff were not undertaking procedures where their training certificates had expired without completing refresher training in that area. This is important for the areas of manual handling, infection control, health and safety and food hygiene as these were the main areas of training looked at. However, the registered manager is aware of this and is arranging training for staff. Also the registered manager is now considering developing an analysis of all training and a method of keeping mandatory training updated in a timely fashion before certificates expire. a training matrix to ensure training certificates of staff members do not run out and that refresher course are provided in good time. Also staff training files sampled contained evidence of certificates where specialist courses have been provided including epilepsy, diabetes, autism awareness and sexual awareness. This will make sure that people are supported by competent and a qualified staff group who have the knowledge and skills to meet people’s individual needs. Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 25 Supervision records were examined and staff spoken with feel that they receive valuable supervision sessions where their training needs are looked at. Staff also felt that they receive sufficient support and supervision to enable staff to fulfil their roles and responsibilities. Also the registered manager stated that she provides staff with the experience of undertaking more senior responsibilities particularly when the registered manager is on annual leave. This shows that the manager is committed to maintaining a stable staff group as she highlighted in her AQAA, ‘Low turnover of staff thus enabling consistency of care practices’. People told us:“They, (staff), are kind and always working hard”. “They, (staff), will do anything you want”. Alsop House DS0000041325.V371945.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further development of the homes quality monitoring systems with regards to gathering people’s views in order to focus upon the best possible outcomes for people needs to be made. Improvements and consistency needs to be maintained in some areas of the homes record keeping policies and procedures which will offer further safeguards to people. EVIDENCE: It was evident that the registered manager is committed to providing the best possible outcomes for people who have respite stays in the home. For example, making sure quality monitoring is undertaken on a weekly basis. So that improvements can be made in the home and practices can be examined to ensure that people’s needs are being met in a timely fashion and safely. It is also another method whereby people are able to express their views on the Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 27 service they receive at the home. Quality monitoring visits are also undertaken by the operational manager on a quarterly basis. The home need to maintain the consistency of their quality monitoring to make sure that it happens on a regular basis and is clearly documented. It is pleasing to see that people have the opportunity of completing questionnaires in relation to the service provided in the home. These now require analysing so that a report based on the findings from the questionnaires can be produced and made available in the home. The registered manager in her AQAA mentioned this as one of the homes areas that they would be developing further. Accident records were well maintained. In line with the Data Protection Act individuals names are not included on the accident records. However, since the homes last inspection the registered manager has now devised a coding system whereby individuals can be identified for monitoring purposes, tracking trends and auditing purposes. This shows that the registered manager is improving the systems within the home to make sure peoples health, safety and wellbeing are promoted and protected adequately. A requirement relating to records has been outstanding since 2004. As at previous inspections staff personnel records continue to be held at the provider’s head office. In view of this 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 Criminal Record Bureau checks, (CRB), 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. Generally health and safety is adequately managed. It was encouraging to see that maintenance and service checks demonstrate areas such as gas appliances, fire equipment and water outlets are being appropriately checked. The registered manager has now developed a folder which relates to checks undertaken by the home and individual staff members are given the responsibility of completing checks and monitoring with guidance when required from the registered manager. A staff member that was responsible for the fire drills and alarm tests showed us the folder and explained what happens. This means that any potential risk to people was now safeguarded by the homes developed practices and procedures. Staff have now received fire training. As stated in the staffing section all refresher courses in mandatory training need to happen in a timely fashion Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 28 before certificates expire to ensure the health, safety and welfare of people are paramount. People told us:“She is lovely and kind”. “She will sit and talk to you”. Alsop House DS0000041325.V371945.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 3 4 5 CONCERNS AND COMPLAINTS Standard No Score 22 23 3 3 3 3 3 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000041325.V371945.R01.S.doc LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Alsop House Score 3 3 2 X 3 X 2 X 1 3 X Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? No 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 YA9 Regulation 13(4) Requirement The home must ensure that peoples changing needs are reflected in their risk assessments and plans. This means that peoples changing needs will be met with risks to their health, safety and wellbeing being minimised. The home must demonstrate that its recruitment records have available evidence in them to ensure vulnerable people are safeguarded by robust recruitment evidence. Timescale for action 26/11/08 2. YA34 13(6) 18(1)(a) 03/11/08 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 The home needs to further improve their medication handling and giving to people so that people are protected from the risk of infection. Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 31 2. YA35 3. YA24 The home must develop an analysis of all mandatory training to ensure that before staff member’s certificates expire the home must have a system of monitoring the need for refresher courses in a timely fashion so that people’s health, safety and wellbeing are not placed at risk. The registered manager has confirmed that she is pursuing the work to three bathroom floors in the home. Once work has been completed the registered manager must ensure CSCI are made aware. That security gates are fitted to the homes car park to ensure people, visitors and staff are afforded security and safeguards are in place. 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 200`(or make a formal request to CSCI to retain documents at head office and obtain approval using new guidance and documentation issued in November 2005). 4. YA41 Alsop House DS0000041325.V371945.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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