CARE HOME ADULTS 18-65
Alsop House 2 Rowland Vernon Way Tipton West Midlands DY4 0RF Lead Inspector
Lesley Webb Unannounced Inspection 29th September 2007 09:15 Alsop House DS0000041325.V348491.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.V348491.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.V348491.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.V348491.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. 20th October 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. 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.V348491.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that was undertaken by one inspector on a Saturday between 9.15am and 5.30pm. During the visit time was spent talking to staff and residents, examining records and observing care practices. Also the care packages of two individuals were case tracked in order to help form judgements on the quality of service provided by the home. The Commission for Social Care Inspection (CSCI) requested information from the home prior to the inspection. Unfortunately this was not received in time to be included in this report. This also resulted in surveys not being able to be sent to service users, families and other interested parties in order to obtain their views on the service that also could have been included in this report. The inspector was shown full assistance during the visit and would like to thank everyone for making her welcome. What the service does well:
The home is good at obtaining assessments from social workers before deciding if a place can be offered to individuals. In addition to this the home also undertakes its own assessment, to ensure it can meet the needs of people. The inspector spoke to three of the four residents currently residing at the home all of whom confirmed staff respect their wishes and that their views are sought with regards to activities, meals and care. As one resident explained, “they do come around and ask what activities you would like to do” and another, “they let you do what you want, it’s great”. Daily routines are flexible and very much tailor made to individual residents’ preferences. Everyone that the inspector spoke to praised the service and its flexibility. As one person explained, “its great here, like home from home. I can do what I want, if this was to be turned into a residential unit I would ask to move here permanently”. Residents confirmed they were happy with the meals and choices offered. As a member of staff explained, “we have a menu but we don’t really stick to that. We look what is in the freezer and offer three choices. People can have different if they want, we try to give a range of choices, including take-away”. In the main residents receive personal support in the way they prefer and require. For example residents preferences about how they are moved and
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 6 supported are recorded and residents were seen being given personal support in the privacy of their bedrooms. Residents that the inspector spoke to confirmed they were aware of the complaints procedure and that they would feel happy to raise any concerns if they should arise. Infection control appears good at this home with all parts of the home seen to be hygienic, clean and tidy. There is a separate laundry that is well equipped with industrial washing machine and dryer. Residents that the inspector spoke to all praised the staff. As one person explained, “I have been coming here for a few years, would come more if I could. Its nice to have people to talk to, the staff are great, I have a laugh with them” and another “Staff try their best”. What has improved since the last inspection? What they could do better:
Risk assessments still require attention in order that residents can be confident the homes management of risks offers sufficient safeguards.
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 7 It was noted that no specific cultural products were available to make meals for a resident currently residing at the home and records indicate meals relevant to this person cultural heritage have not been offered. It is recommended work be undertaken to ensure residents are offered meals that meet their cultural preferences, with records maintained, to ensure no one is discriminated against. At this inspection the overhead tracking in one of the bedrooms and the communal bathroom was broken, with staff and residents confirming the communal bathroom has not been accessible for a considerable amount of time and despite the tracking in the bedroom being repaired recently this has again failed. It is acknowledged that all bedrooms have ensuite shower facilities but the bathroom would offer a choice with regards to bathing or showering to residents. As one resident explained, “it would be nice to have a choice”. The inspector observed the morning and afternoon medication being dispensed. Staff were seen signing the medication administration sheets before giving medication to residents and putting pieces of paper in with medication in order to identify which residents medication it was due to dispensing more than one persons medication at a time. Two members of staff were involved in these practices, with neither showing any awareness of these bad practices. Due to the potential risks to residents an Immediate Requirement form was issued instructing that these practices cease with immediate affect and for confirmation to be sent to the CSCI within 48 hours that staff will receive further guidance with regards to administering and recording of medication. During the inspection children from neighbouring areas were seen throwing bricks and other items in car park and running around this area of the property. It is strongly recommended that security gates be fitted to the car park in order to offer further security and safeguards to residents, staff and visitors. 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 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 requirement was first made in 2004 relating to quality assurance systems and although improvements continue further work is still recommended. Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 8 Action must be taken to reduce the risk of injury from bedrails. For example one residents file was found to contain a risk assessment for bed rails due to this person being at high risk. The assessment states that due to risk of entrapment ‘checks to be made and bumpers to be used if any’. The inspector explored this situation further and found that the home has only one set of rail protectors for the four beds that have rails in place. This persons rights to privacy are being compromised due to insufficient amounts of rail protectors resulting in checks having to be undertaken by staff. Improvements must also be made with regards to fire training for staff. No evidence could be found of any of the staff working at the home having undertaken fire training within the last twelve months. Records demonstrate a fire drill taking place September 2007 but this did not include the names of individuals and therefore could not evidence sufficient numbers of staff having participated. Due to the potential risk to service users regarding the lack of fire training an Immediate Requirement Form was issued. 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.V348491.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.V348491.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): 1,2,3,4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people considering this service have information needed to decide on its suitability. They have their needs assessed and a contract that clearly tells them about the service they will receive. EVIDENCE: A previous requirement to amend the Service User Guide is now met. A copy of this was sent to the Commission for Social Care Inspection (CSCI) prior to the inspection and found to contain specific information regarding the service provided at Alsop House, ensuring prospective service users have the information they need on which to base decisions. The case files of two residents were examined, with both containing a care plan from the placing officer that had been received prior to the resident’s admission, as is good practice. In addition to this the home also undertakes its own assessment, with this covering all areas as detailed in the National Minimum Standards 2.2. 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
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 11 are suitable for the prospective new service user. It was pleasing to find evidence of all files sampled written confirmation that residents receive a copy of the statement of purpose and service user guide, have been made aware of the contents of care plans and have been given a copy of their contract of residency. Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. 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: As at previous inspections 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. A requirement was made at the previous inspection to ensure care plans cover in sufficient detail all aspects of personal, social and health care needs, for example with regard to pressure area care or nutrition. Work is progressing to address this but further work is still required. For example one persons
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 13 assessment identifies cultural requirements relating to skin and hair care but none of this information has been transferred into a plan of care to ensure this persons needs will be met in full. The same person file contained a nutritional assessment stating they are at high risk in this area but again no plan of care was in place detailing how this will be managed. A second residents file contained detailed and informative information that had been supplied by this person’s family. Some of this information had been transferred into care plans but other areas had not. Staff confirmed they were in to process of updating care planning documentation, which is a positive. This should now be given priority in order that residents can be confident the home will meet their needs in full. In the main residents who use the respite service at Alsop House are able to be fully involved in decision making processes regarding their care and services provided by the home. The inspector spoke to three of the four residents currently residing at the home; all of whom confirmed staff respect their wishes and that their views are sought with regards to activities, meals and care. As one resident explained, “they do come around and ask what activities you would like to do” and another, “they let you do what you want, it’s great”. As identified at previous inspections, risk assessments still require attention in order that residents can be confident the homes management of risks offers sufficient safeguards. For example one residents file was found to contain a risk assessment for bed rails due to this person being at high risk. The assessment states that due to risk of entrapment ‘checks to be made and bumpers to be used if any’. The inspector explored this situation further and found that the home has only one set of rail protectors for the four beds that have rails in place. This persons rights to privacy are being compromised due to insufficient amounts of rail protectors resulting in checks having to be undertaken by staff. Another residents file contained a risk assessment for the use of bed rails that states ‘bumpers not required’. In all cases where bed rails are used rail protectors should be in place to reduce the potential risk to residents. If a resident requests these are not used, this should be clearly recorded to ensure the service can demonstrate everyone is aware of their rights and responsibilities. Another person had a care plan for personal care with a risk assessment attached but this was blank. This same person had a moving and handling risk assessment for transferring from bed to chair that states ‘to review at next stay due to high risk’. No evidence could be found of this occurring. Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to 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. Generally meals are good, offering both choice and variety. EVIDENCE: Residents confirmed that they are supported to access the local community and can participate in a range of activities. As one person explained, “A chap came this morning and took me out, we went to Merry Hill I enjoyed it”. 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. 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
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 15 established owned by the same provider. It was pleasing therefore to be informed by staff that arrangements are in hand and that a new bus should be in place later in the year. This was also confirmed by one resident who is particularly looking forward to this. As they explained, “they are getting their own bus December so I will be able to go out with the others, I cant at the moment because the bus they have is too small and I cant fit my wheelchair in, it will be nice to go out as a group”. Daily routines are flexible and very much tailor made to individual residents’ preferences. For example, on arrival at 9.30am one resident was up, ready to go out on an activity and others were in various stages of rising. Residents were observed washing up in the kitchen, watching television and sitting outside in garden area. Residents seen retiring to their rooms or choosing the company of others. Everyone that the inspector spoke to praised the service and its flexibility. As one person explained, “its great here, like home from home. I can do what I want, if this was to be turned into a residential unit I would ask to move here permanently”. There is a menu in place however this is not always used. As a member of staff explained, “we have a menu but we don’t really stick to that. We look what is in the freezer and offer three choices. People can have different if they want, we try to give a range of choices, including take-away”. Residents confirmed they were happy with the meals and choices offered. When examining the kitchen an abundance of food products were in place including fresh, dried goods and frozen items. It was noted that no specific cultural products were available to make meals for a resident currently residing at the home and records indicate meals relevant to this person cultural heritage have not been offered. It is recommended work be undertaken to ensure residents are offered meals that meet their cultural preferences, with records maintained, to ensure no one is discriminated against. Alsop House DS0000041325.V348491.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: In the main residents receive personal support in the way they prefer and require. For example residents preferences about how they are moved and supported are recorded and residents were seen being given personal support in the privacy of their bedrooms. As already mentioned times for rising and retiring, meals and other activities are flexible according to individuals needs and preferences. There are a number of aids and adaptations to promote residents’ independence. For example there is overhead tracking in two bedrooms and a communal bathroom. There is also a portable hoist. Kitchen surfaces are adjustable and all bedrooms have ensuite level access showers. At this inspection the overhead tracking in one of the bedrooms and the communal bathroom was broken, with staff and residents confirming the communal bathroom has not been accessible for a considerable amount of
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 17 time and despite the tracking in the bedroom being repaired recently this has again failed. No evidence could be found of action being taken to repair the tracking in the bathroom and this facility is currently being used to store items of furniture. It is acknowledged that all bedrooms have ensuite shower facilities but the bathroom would offer a choice with regards to bathing or showering to residents. As one resident explained, “it would be nice to have a choice”. 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. 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. The inspector observed the morning and afternoon medication being dispensed. Staff were seen signing the medication administration sheets before giving medication to residents and putting pieces of paper in with medication in order to identify which residents medication it was due to dispensing more than one persons medication at a time. Two members of staff were involved in these practices, with neither showing any awareness of these bad practices. Due to the potential risks to residents an Immediate Requirement form was issued instructing that these practices cease with immediate affect and for confirmation to be sent to the CSCI within 48 hours that staff will receive further guidance with regards to administering and recording of medication. As Alsop House offers a respite service a monitored dosage system for the management of medication cannot be used. The records and medication of two residents were examined with all aspects correct and in good order apart from a medication for one resident. Staff took action to rectify this immediately. A number of requirements and recommendations have been made at previous inspections with regards to medication, the majority of which are now met, which is a credit to the service. For example the medication policy has been amended, the written consent of service users has been obtained for staff to administer their medication and where instructions on dispensing labels differ from instructions given by service users clarification is now sought from general practitioners, with records maintained. The majority of staff have undertaken medication training, however it is recommended that the home obtain the CSCI guidance regarding medication training and competency assessments and implement these to ensure practices reflect current good practice guidance and to offer further safeguards to residents. It is also recommended that the temperature in the medication cabinet be monitored to ensure medication is stored as per manufactures guidelines. Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 18 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 individuals are reassured their concerns are listened to and acted upon. There are policies and procedures in place to safeguard people from abuse. EVIDENCE: As at the previous inspection there have been no complaints received by the Commission regarding Alsop House during the last twelve months. 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 timescales. In addition to this the complaints procedure is on display at the entrance to the home and all case files sampled contained evidence that residents have been given a copy of this. Residents that the inspector spoke to confirmed they were aware of the complaints procedure and that they would feel happy to raise any concerns if they should arise. 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. Since the last inspection the manager has obtained a copy of the Department of Health guidelines regarding the Protection of Vulnerable Adult (POVA). It is strongly recommended that information regarding referring staff
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 19 unsuitable for working with vulnerable adults be included in the organisations protection policies to ensure everyone is fully informed. Residents 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. Monies held on behalf of residents were found to be accurately recorded on the individual records of residents. When talking to one resident they confirmed that the service was holding money on their behalf but that they would have preferred to keep this themselves but the lockable facility in their room was broken. Action should be taken by the home to ensure lockable facilities are available in all bedrooms to ensure facilities enable residents to retain their finances as they wish. Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 20 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 to 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a generally safe and comfortable environment. Work is needed to ensure all facilities are maintained to a good standard in order to promote choice and independence. EVIDENCE: A tour of the premises was undertaken and residents’ bedrooms viewed with their consent. Alsop House has been built to a high specification in order to meet the needs of people with physical disabilities and includes height adjustable kitchen surfaces, ensuite shower facilities for all bedrooms and overhead tracking. Since the last inspection stained carpets have been replaced and raised manhole covers and broken slabs made safe (meeting previous requirements). Staff also confirmed that arrangements are in hand to carry out redecoration of the bedrooms. Communal areas were seen to be decorated and furnished to a good standard. They are bright, airy and well
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 21 ventilated. As mentioned earlier in this report the tracking in the communal bathroom and one of the bedrooms was broken on the day of inspection, with the bathroom being out of commission for some time. Action must be taken to ensure repairs to equipment such as overhead tracking takes place in a timely fashion to ensure residents are able to use all facilities within the home and to promote their rights to choice. There are manual hoists available for use, but as one resident explained, “The manual hoist is jerky as its pumped up, the overhead tracking is much smoother and allows you to go from your bed straight into the shower which is much better”. It was also noted that some of the shower rooms require attention to the flooring where this appears to have come away allowing water to run underneath. There is a large, private garden to the rear of the home and parking facilities at the front. During the inspection children from neighbouring areas were seen throwing bricks and other items in car park and running around this area of the property. Staff asked them to leave but this distracted them from undertaking their care duties. It is strongly recommended that security gates be fitted to the car park in order to offer further security and safeguards to residents, staff and visitors. Infection control appears good at this home with all parts of the home seen to be hygienic, clean and tidy. There is a separate laundry that is well equipped with industrial washing machine and dryer. The appropriate personal protective equipment was seen to be well stocked and with staff observed using these as good practice throughout the inspection. There are two sinks, one for hand washing and the other for sluicing. There is currently no procedure for the sanitizing and storage of mops and the home has a copy of infection control guidelines for residential homes that is out of date. It is recommended the home obtain a copy of the latest guidance and implement procedures for the sanitizing and storage of mops to ensure practices reflect current good practice and promote good infection control. It was also noted that the homes infection control policy dated September 2006 states that Inhouse training will be provided at least annually. No evidence of this taking place as per the policy could be found. Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 22 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): 31,32,33,34,35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally staff are training, skilled and in sufficient numbers to support the people who use the service. The home must be able to demonstrate that its recruitment practices safeguard people. EVIDENCE: As at previous inspections staff demonstrated a commitment to their job roles and a good understanding of the needs of the service user group its great here. This was reinforced by residents that the inspector spoke to, all of whom praised the staff. As one person explained, “I have been coming here for a few years, would come more if I could. Its nice to have people to talk to, the staff are great, I have a laugh with them” and another “Staff try their best”. Training files sampled contained evidence of certificates. Specialist training has been provided including epilepsy awareness, diabetes and sexual awareness. 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. Discussions with staff and examination of rotas demonstrate that between two and three
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 23 staff are on duty during the morning and afternoon and a waking member of staff and sleep-in person during the night. In addition to this the manager undertakes the majority of her hours supernumery to care. There are regular staff meetings where a good range of topics are discussed. Recruitment records are maintained at the services central head office. This inspection took place at the weekend with staff confirming they were unable to access recruitment records. This issue has been discussed previously with the registered provider and a requirement 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 training matrix dated 14 May 2007 and individual staff training folders were examined to ascertain numbers of staff that hold a national vocational qualification (NVQ). Of the three staff files sampled all three contained evidence they hold a NVQ qualification. Information regarding NVQs’ is currently not recorded on the training matrix; it is recommended this information be included in order to enable the home to demonstrate suitable numbers of staff hold this qualification. It was also noted that some of the individual training needs analysis forms in place on individual staff files need updating and they did not always reflect certificates maintained in their files. Supervision records were not accessible during the inspection, with staff explaining that these are stored securely with only the manager having access. All staff that were spoken to did however state that they feel they receive sufficient support and supervision to enable them to fulfil their roles and responsibilities. Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 24 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): 37,39,41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the service is based on openness and respect. Quality monitoring systems need developing further and should include the views of people in order it can measure effective outcomes for people. Improvements in some areas of health and safety will offer further safeguards to people. EVIDENCE: The registered manager was not present during this inspection, however in the main evidence gained indicates she is fulfilling her role and responsibilities. Staff on duty confirmed the registered managers commitment to her role, for example one person explained, “she is always there, we only have to telephone, even when she is not on duty”.
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 25 The homes quality monitoring processes were examined including reading the organisations quality statement, sampling of reports and other documentation. The quality statement informs the reader that weekly checks by the manager and quarterly inspections by the operations manager will be undertaken and that questionnaires for services users will be distributed on a regular basis. Evidence was found that some aspects of the statement are being followed but that other areas are not. For example the last weekly check record undertaken by the manager is dated 26/04/07 and the operational managers last quarterly report is dated Jan-march 2007. Monthly reports in line with Regulation 26 of the Care Home Regulations 2001 were in place for January 2007 to April 2007 with no others available for viewing. Service user surveys were seen to be in place but none of these were dated and no evidence could be found to verify which year they applied to. An annual development plan dated April 2006 to March 2007 details decoration/ maintenance issues but no other developmental areas relating to the home including the findings from service user surveys. A requirement was first made in 2004 relating to quality assurance systems and although improvement continue further work is still recommended. It was pleasing to find that residents meeting take place on a regular basis where subjects such as activities, menu, complaints and staff are discussed. It is recommended that the minutes of these be expanded to evidence action taken to address issues/requests made by service users. A requirement relating to records has been outstanding since 2004. As at previous inspections 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. Generally health and safety is adequately managed. Since the last inspection a separate hand washing facility has been installed in the kitchen area (meeting a previous requirement) and a random sample of maintenance and service checks demonstrate areas such as gas appliances, fire equipment and water outlets are being appropriately checked. As mentioned earlier in this report action must be taken to reduce the risk of injury from bedrails. Improvements must also be made with regards to fire training for staff. No evidence could be found of any of the staff working at the home having undertaken fire training within the last twelve months. Records demonstrate a fire drill taking place September 2007 but this did not include the names of individuals and therefore could not evidence sufficient numbers of staff having
Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 26 participated. Due to the potential risk to service users regarding the lack of fire training an Immediate Requirement Form was issued. Systems for monitoring accidents are in place including the completion of accident records and monitoring forms for falls. In line with the Data Protection Act individuals names are not included on the accident records, which is a positive, however a coding system is not in place that allows for monitoring incidents to individuals. A member of staff was able to relate certain accidents to particular service users but not all. Improvements in this area will promote the health and safety of residents further. As mentioned earlier in this report there is a rolling programme for staff training. This includes training in food hygiene, manual handling, first aid and health and safety. Records maintained at the home indicate that some staff require updates in food hygiene and manual handling. Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 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 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 X 1 2 X Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 28 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. Standard 1 YA9 Regulation 13(4) Requirement To carry out individual written risk assessments with regard to all aspects of care in order to reduce the risk to residents (Previous timescale of 1/10/03 is partly met). Action must be taken to ensure repairs to equipment such as overhead tracking takes place in a timely fashion to ensure residents are able to use all facilities within the home and to promote their rights to choice. That the services policies and practices with regards to medication improve in order to reduce the risk to residents – Immediate Requirement form issued. That confirmation be sent to CSCI that staff will receive further guidance with regards to administering and recording of medication – Immediate Requirement Form issued. The home must be able to Timescale for action 31/12/07 2 YA18 23(2)(c)((n) 01/11/07 3 YA20 13(2) 30/09/07 4 YA20 13(4)(6) 05/10/07 5 YA34 13(6) 18(1)(a) 01/12/07
Page 29 Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 6 YA41 17(2) 19 7 YA42 13(4) 8 YA42 23(4)(d)(e) demonstrate that its recruitment practices and records safeguard residents. 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 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). Action must be taken to reduce the risk of injury from bedrails – Immediate Requirement Form issued. Action must be taken to ensure staff receive fire training and participate in regular fire drills to reduce the risk of injury in the event of a fire – Immediate Requirement Form issued. 01/12/07 05/10/07 05/10/07 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 YA6 YA13 YA17 Good Practice Recommendations To continue to ensure that care plans cover in sufficient detail all aspects of personal, social and healthcare needs, in order that residents’ needs are met in full. To purchase a more suitable or second vehicle in order to accommodate all wheelchair users. That work be undertaken to ensure residents are offered meals that meet their cultural preferences, with records
DS0000041325.V348491.R01.S.doc Version 5.2 Page 30 Alsop House 4 5 YA18 YA20 maintained, to ensure no one is discriminated against That the communal bathroom be reinstated in order that residents have a choice of bathing facilities. That the home obtain the CSCI guidance regarding medication training and competency assessments and implement these to ensure practices reflect current good practice guidance and to offer further safeguards to residents. That the temperature in the medication cabinet be monitored to ensure medication is stored as per manufactures guidelines. That information regarding referring staff unsuitable for working with vulnerable adults is included in the organisations protection policies to ensure everyone is fully informed. To ensure lockable facilities are available in all bedrooms to ensure facilities enable residents to retain their finances as they wish. 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 carry redecoration of bedrooms were paintwork has become damaged and worn. That attention is given to the damaged flooring in some of the shower rooms. That security gates be fitted to the car park in order to offer further security and safeguards to residents, staff and visitors. That the home obtain a copy of the latest guidance ‘Infection Control in Residential Homes’ and implement procedures for the sanitizing and storage of mops to ensure practices reflect current good practice and promote good infection control. That staff receive in-house infection control training annually as stated in the homes infection control policy dated September 2006 to promote good practice. That information regarding NVQs’ is included on the training matrix in order to enable the home to demonstrate suitable numbers of staff hold this qualification. 6 YA23 7 YA24 8 YA30 9 YA35 Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 31 10 11 YA36 YA39 That individual training needs analysis forms are updated to reflect certificates maintained in training files. That a system be introduced that enables the home to demonstrate staff receive regular, formal supervision. That the home complies with its own quality statement and ensures weekly checks by the manager and quarterly inspections by the operations manager will be undertaken and that questionnaires for services users will be distributed on a regular basis in order that it can measure if it is achieving its aims and objectives. That records are maintained within the home of monthly reports in line with Regulation 26 of the Care Home Regulations 2001 are being undertaken. That the annual development plan includes the findings from service user surveys. That the minutes of service user meetings be expanded to evidence action taken to address issues/requests made by service users. A system should be introduced that allows for effective monitoring of accident records. Updates in food hygiene and manual handling training for some staff should be undertaken in order to maintain their knowledge and promote good practice. 12 13 YA42 YA42 Alsop House DS0000041325.V348491.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Halesowen Local Office West Point Mucklow Office Park Mucklow Hill Halesowen 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
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