Inspection on 16/11/05 for Bells Court

This inspection was carried out on 16th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 39 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bells Court 24/04/06

Bells Court 02/08/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Bells Court 239 Bells Lane Druids Heath Birmingham West Midlands B14 5QH Lead Inspector Joe O`Connor Unannounced Inspection 16th November 2005 10:15 Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 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 Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 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. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bells Court Address 239 Bells Lane Druids Heath Birmingham West Midlands B14 5QH 0121 459 1883 0121 459 2249 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) Care Through The Millennium Mr Gregory M Zhuwao Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 with a learning disability. In addition to the manager a minimum of one other suitably qualified and experienced member of staff must be provided throughout the waking day, that is 7:30 till 22.00. During the night there must be 2 awake night staff on duty. Date of last inspection 2nd August 2005 Brief Description of the Service: Bells Court is a three bedroomed detached property located off a main road in the Druids Heath area of Birmingham. The service is registered to accommodate three adults with learning disabilities providing residential care and a day service. Bells Court is close to local bus routes for Birmingham, Shirley and Solihull. It is also close to local amenities including the Maypole Shopping Centre. The premises consist of three single bedrooms with en-suite shower, toilet and wash hand basins located on the first floor. On the same level there is a laundry that has a washing machine with a sluice programme. The ground floor has two comfortable lounges, one of which is used as a quiet room. There is a spacious kitchen/dining area that is fully equipped. A bathroom with toilet and hand wash facilities is situated on the ground floor that has handrails fitted to assist with access. An office is also situated on the ground floor. The property is accessed via a service road that is altered by high fencing, shrubs and ornamental trees providing security and privacy. There is a gate to the front of the property and is accessed by an electronic keypad. This leads into a driveway. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a day and was unannounced. Two service users were able to convey their views on life in the home. The Inspector spoke to the Registered Manager. A tour of the premises was undertaken. Service users care plans and risk assessments were inspected. Staff recruitment and training records were also examined and a number of health and safety records were also sampled. What the service does well: What has improved since the last inspection? There have been limited improvements since the last inspection. The manager stated that all service users had a key to their bedroom since the last inspection. One service user stated that this was the case as he had asked for one at the time of the previous visit. The manager had also ensured copies of prescriptions were being attached to the Medicines Administration Records or MAR sheets, as they are known to check the medication being received before dispensing had the correct details before administering to the service users. The manager had addressed a requirement from the previous inspection for the staff rota to clearly identify the hours worked by staff during the day and at night. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 6 What they could do better: There has been little in the way of development of service users care plans to show how the needs of the service users are being met. The risk assessments do not adequately cover how certain individuals with challenging behaviour should be addressed and strategies are in place to prevent further incidents. One service user commented that since his arrival during August 2005 he had not been offered treatment from a dentist, chiropodist, and optician. The manager must address this. It was also noted that nutritional assessments for service users had not been completed which was a requirement from the previous inspection. Service users weight was not being recorded on a monthly basis. The management of medication was found to be of an unacceptable standard and had not improved since the last inspection. This is potentially placing service users at risk. The welfare and safety of service users were not adequately safeguarded. A number of incidents including a service user absconding from the building had not been notified to the Commission. An examination of the fire records found there had been gaps in the recording of the fire alarms and emergency lighting. There was no risk assessment for the prevention of fire. There was little in the way of interaction between staff and two of the service users while they spoke mainly to another who was more able than the others. Two service users expressed concern about the behaviour of staff. One service user stated he had been hit twice by other service users, and nothing had been done by staff to stop this. Another stated that staff behaved inappropriately while he was on holiday. Staff have not received training in adult protection and the manager and The Registered Provider must take firmer action in ensuring staff protect the service users interests and respond to any concerns. Another service user expressed unhappiness at having to go on holiday to Spain when he wanted to go on one with his girlfriend and not have to go with the other service users. He felt there was no choice with this. The service user had twice raised in monthly meetings with staff that he had a poor picture on his TV but there was no record of whether his concerns had been addressed. The manager has a lot of work to do in ensuring the service users needs are appropriately met and should seek a full review with the relevant professionals involved. The current group of service users do not appear to be getting on with each other. There have been a lot more requirements issued in this report that is of concern to the Commission. A stronger management approach is required not only from the manager himself but from the organisation that benefits service users and provides them with a safe environment. Staff do not have adequate levels of supervision. The Commission may have to consider enforcement action if at the next visit there has been a lack of progress in addressing the requirements some of which are now outstanding. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 7 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. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 Service users do not have information available that informs them of the service being provided. Service users do not have individual statement of terms and conditions informing them of what they are being charged for their stay. The service’s capacity to meet the current needs of the service user group must be reviewed to ensure they receive appropriate care and support. EVIDENCE: The service does have a Statement of Purpose but there was no copy of the Service Users Guide available for each service user. An examination of service users records found they did not have a current copy of their statement of terms and conditions. A blank copy of a statement of terms and condition did not make clear whether service users had to pay towards the cost of transport. Two service users provided comments about the support they were receiving. One commented that he has his ups and downs with staff but was satisfied with the support he was receiving. The service user stated that one day he would like to move into supported living but was not ready for this. Another service user stated that he liked living in his accommodation but did not like the other two because he alleged there were occasions where they had hit him and tried to get into his bedroom. Staff had done nothing about this. It was apparent from discussion with the service user he was unhappy and seemed very anxious. An examination of service users records and in discussion with the manager indicated the current group of service users are not gelling since the service was first registered in May 2005. With these issues in mind the Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 10 manager must make serious consideration to review each service users’ needs in liaison with the relevant professionals involved in the care of the service users. The care records for each service user however, did not provide a full picture around the needs of the service users, as there were no structured care plans in place. A number of health and safety issues referred to in the relevant section of this report give cause for concern as to whether the service is managed in a robust way that protects the interests of service users. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 9, 10 Service users do not have care plans that set out how their needs are to be met. They do not provide information with regard to individual daily routines. Service users risk assessments do not demonstrate how any concerns with regard to challenging behaviour are to be managed. Service users’ confidentiality is not being maintained to an acceptable standard. The minutes of service users meetings do not demonstrate how any service users requests have been addressed. EVIDENCE: It was of concern to find that no improvements had been made to the service users care plans since the last inspection. The manager stated that he was currently updating the care plan but there were blank copies on the service users records. Therefore no evidence was available to confirm how the needs of all three service users were to be met. Further examination of the records found there had been changes to one service user’s behaviour but the risk assessments for these had not been reviewed or updated to reflect these changes. In addition there was no evidence of what reactive strategies were in place to prevent further incidents of challenging behaviour. There was no evidence that the service users had a review with their keyworker. Improvements must be made to the development of service users care plans Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 12 that reflect their individual needs and involve the service users in their development or the Commission may have to consider enforcement action. There was some evidence that service users are involved in monthly meetings and it was documented those service users who had refused to take part. The minutes seen were for August and October 2005. There was no meeting for September. The minutes for the meeting were very brief but it was noted that some concerns raised by one service user had not been followed up by staff. The service user had stated twice that no one had addressed the problem of improving the quality of picture on his TV set the service user also expressed dissatisfaction with how the holiday arrangements had been made, as he wanted to go on holiday to Blackpool with his girlfriend. The minutes of the meetings must include an action plan to address any service users requests and concerns after each meeting. Issues around confidentiality of service users were raised with the manager as much of the entries in the communication book had a number of entries that should have been written in their daily notes and their names initialled. The service does have a confidentiality policy and the records were locked in a secure facility in the office. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 17 Service users with staff support are able to access activities in the community. There is a lack of interaction between certain service users and staff that do not demonstrate positive relationships within the service. Service users have access to leisure activities but there is a lack of choice in choosing a holiday that meets their individual requirements. Service users do not have access to menus informing them of the choice of meals available to them. EVIDENCE: On arrival for the inspection two service users were going out to the Sea Life Centre in Birmingham. One service user later commented that he had enjoyed the trip. The remaining service user was out at a centre known as Birmingham Industrial Therapy Association, which provides employment with a weekly wage that does not impact on the individual’s benefits. The service user stated he enjoyed going to BITA and was pleased to be earning some money. He also stated he goes to watch his favourite football team Aston Villa. The activity records for the service user confirmed this. An examination of other daily activity sheets found service users had participated in activities such as bowling, snooker, cinema and trips out to Wellsbourne Market. It was noted that service users were receiving input from a trained counsellor who was Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 14 involving them in Reiki and Tai Chi relaxation therapies to deal with any anxieties. All three service users had gone on holiday to Tenerife but there was no evidence to confirm whether they had chosen to go together. One service user stated he wanted to go on holiday with his girlfriend. An examination of service users’ daily records indicated that the relationships between service users were poor and it was noted during this inspection there was very little interaction between the service users. Staff were observed to be speaking exclusively to one service user who is very able. A member of staff was observed to be using a mobile phone while sitting in the lounge with two service users. Two service users were observed speaking to their parents by telephone during this inspection. In conversation with two service users both stated they had received keys to their bedroom since the last inspection but there was no evidence on their records to confirm this. An examination of the food records found there were no menus in place to confirm whether service users were receiving a varied and nutritious meal. The cupboards, refrigerator and freezer were well stocked. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Service users nutritional needs have not been assessed and the monitoring of service users’ weight is not monitored regularly. Medication management is has not improved since the last inspection, placing service users potentially at risk. EVIDENCE: The current group of service users are all male and there are adequate male carers providing appropriate gender care support. An examination of service users care plans referred to where service users had completed personal care tasks such as bathing or having a shave. Each service user has a manual handling assessment. Service users are registered with a single GP and two care records examined found they had access to a dentist, optician and chiropodist. It was noted when examining the care records that a requirement for nutritional assessments to be completed had not been addressed. The records for service users weight were not being completed on a monthly basis. One service user commented that since his arrival in August 2005 he had so far not been offered visits to the dentist, optician and chiropodist. An examination of this individual’s record confirmed this was the case. The same service user had been assessed by an occupational therapist since the last inspection but there was no report or record concerning the outcome of their visit. With these concerns in mind the manager must develop individual health action plans that are within the spirit of the D.O.H Guidance Valuing People Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 16 The management of medication was found to be of an unacceptable standard and needed improving. Certain practices are potentially placing service users at risk. Hand written entries on the Medicines Administration Records for medication prescribed midway through the four week period, did not have the amounts and strength recorded. Medication newly prescribed for one service user to be used as PRN or when required did not have a written protocol. One service user who was receiving Rantidine tablets from a blister pack had three tablets removed from week four of the blister pack with no explanation for this. A service user who was prescribed paracetamol tablets did not have this printed on their MAR sheet. A service user who had been prescribed Lorazepam tablets to help overcome his fear of flying to the holiday destination did not have this medication written on their MAR sheet, nor was there any written protocol in place to state why this was needed. This medication was found to be in the medicines cupboard and had not been returned to the supplying pharmacist. There was evidence of where medication had been given but not signed for by staff. An entry in the manager’s diary found that training had been arranged for staff with Boots for training in their Monitored Dosage System later in November 2005. However, the manager was instructed of the need for more in depth accredited medication training. The medication procedure had not been amended since the last inspection to state that any medication errors were to be reported to the CSCI. It was noted there were no arrangements or protocols in place for service users regarding the administration of homely remedies. There was a form in place for service users to state whether they wished to give staff consent to administer their medication but these had not been signed by the service users. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users are not fully protected due to a lack of training for staff and an absence of a robust system for the reporting and recording of incidents of abuse. Service users complaints are not adequately recorded. The adult protection policy and procedure does not inform service users who will provide them with support in the event of abuse being reported. The management of service users personal allowances need to be more robust for the protection of service users interests. EVIDENCE: A complaints procedure is available to all service users but a requirement from the previous inspection for this to be amended had not been addressed. The complaints procedure must state that no one will be victimised for making a complaint and that the CSCI can be contacted at anytime. Two complaints have been received by the service and the CSCI since the last inspection. The service user who made the second complaint had requested this was withdrawn as he had resolved his concerns with the manager. There was no evidence that a record of these complaints had been made. The adult protection policy and procedure had not been amended since the last inspection. A copy of the latest Multi Agency Adult Protection Guidelines published by Birmingham Social Care & Health was in place. There was no evidence to confirm that staff had completed training in adult protection since the last inspection. The Care Director of the organisation who was present at the previous inspection stated this would be booked for the remainder of the year. In conversation with a service user he disclosed that he had been subject to physical assaults from two other service users including when he had been on Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 18 holiday. The service user also stated that the other service users repeatedly try and gain access to his bedroom. The manager was instructed to contact the service user’s social worker under adult protection procedures. An examination of service users’ personal allowances found two signatures were not always in place for all transactions particularly where monies had been taken out. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Service users live in a clean, homely environment that is decorated to a high standard. Improvements are required with regard to infection control practices to maintain service users health and safety. Service users have suitable bathing facilities including en-suite shower in their bedrooms. There is adequate shared space available that is comfortable for service users. Service users bedrooms are decorated and individually personalised to suit their lifestyle. EVIDENCE: The premises was found to be clean, tidy and smelled fresh. Service users were observed to move freely around the property. A tour of the premises was undertaken. Each service users’ bedroom was decorated to a high standard and individually personalised. No measurements were taken at the time of this inspection but the Statement of Purpose stated the bedrooms met the spatial requirements of the National Minimum Standards. The furnishings and fittings provided were of a high standard. The bedrooms have en-suite shower facilities with toilets and wash hand basins. The house has two lounges one with a TV and DVD player including a SKY TV satellite receiver box. The smaller lounge is used as a quiet room and has a stereo system and payphone. There is a large kitchen that is also used as a Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 20 dining room. New dining table and chairs had been purchased since the last inspection. A bathroom is located on the ground floor that is fitted with grab rails. A separate laundry facility is located on the first floor with a washing machine that has a sluice programme. Improvements were required with regard to the control of infection. There were no disposable paper towels in the kitchen and ground floor bathroom. It was noted towels and bars of soap were left lying around in the bathroom. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35, 36 Staff rotas do not reflect who is on duty during the day and night. Service users interests are not adequately protected due to the lack of a robust recruitment practice. The organisation has not provided appropriate training to enhance staff development and meet the needs of the service users. Staff do not have frequent levels of supervision to enable them to undertake their duties effectively. EVIDENCE: An examination of the staff rota found that the registered manager is part of the staff team and the rota does not reflect where those care hours are recorded. It was noted the staff rota had been amended to state the hours worked by staff, which was a requirement from the previous inspection. The Registered Provider must bear in mind that good practice requires the manager to be supernumerary to the rota. Further examination of the rota found the number of staff on duty did not reflect what had been written for the rota. For example one day the rota stated there were three staff on duty during the day when there were only two written on the rota. There were gaps on the rota that did not confirm whether there were two night waking members of staff on duty. Since the last inspection one member of staff had left the service and three new members of staff had been recruited including a night waking carer. An examination of staff records found them to be unsatisfactory. One file examined found there was no proof of identity and evidence of a CRB check. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 22 There was also no record of any induction. Two other staff files examined did not have evidence of CRB checks. It was noted that one member of staff who had transferred from another service within the organisation did not have an up to date record to reflect the new service she was working in. Another staff file sampled found there was no application form. There were no up to date contracts. No job descriptions were in place for those who had recently been employed. While there was evidence of two references there were no copies of letters on the files requesting these. An examination of the staff training records indicated that not all staff had completed mandatory training topics in areas such as food hygiene, manual handling, first aid and infection control. Specialist training in areas such as physical intervention, autism, challenging behaviour, epilepsy and forensic work had not been arranged since the last inspection. The manager must develop a training matrix that identifies future training needs for all staff and address any gaps where updated training is required. When examining the staff records it was noted that the levels of supervision were in need of improving. One file sampled of a newly recruited member of staff found she had not received supervision since commencing employment in July this year. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 The manager must improve practice to ensure effective management of the service that benefits service users. Service users interests are not protected in full due to incomplete records. Service users’ health and safety is not adequately maintained potentially placing them at risk. Service users do not have regular opportunity to comment on the management of the service. EVIDENCE: The Registered Manager demonstrated some understanding of the needs of the service users and was keen to improve practice. He is qualified to the Registered Managers Award. The manager does have a great deal of work to do in developing service users care plans and ensuring the management of service users’ medication is to an acceptable standard. The overall view as to the management of the service is a more robust monitoring of the service is required from the Registered Provider that ensures safe working practices within the service and that staff are provided with up to date training to enable them to carry out their duties effectively. Given the significant number of requirements issued in this report the service has not made any improvements that meet the outcomes for the service users. There are a number of Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 24 outstanding requirements that must be addressed. An issue was raised with the manager with regard to his work with his former employer, currently working two nights as a night waking carer. The manager was informed that this should now cease as it was a conflict of interest and likely to be impacting on his commitment to this service. A representative from the organisation visits the service but it was noted these visits were not occurring every month. The service does not have a quality assurance system and the Registered Provider and manager must ensure a system for reviewing the service it provides is in place. The service has a range of policies and procedures that were signed by staff to confirm they had read them. The records held on the premises were found to require updating particularly including the service users care plans and staff recruitment records. They were locked in a secure facility in the office. Records with regard to health and safety were found to be unsatisfactory. The fire alarm weekly test record found a number of gaps and there were also gaps in the records for the monthly testing of the emergency lighting. A fire drill had occurred since the last inspection but there was no record of who had participated in the drill. It was noted that staff were now overdue for updated fire safety training. There was no risk assessment in place for the prevention of fire and there was no risk assessment for the premises. The fire alarm system had been serviced prior to this inspection. There was a locked cupboard for the storage of materials used under COSHH Regulations but there were no product data sheets in place. The accident book was examined and it was found there had been no accidents since the last inspection. However an entry in one service users’ daily progress notes referred to an incident where he had fallen on the landing and hurt himself. This was not written in the accident book. Another incident where a service user had left the premises without agreement from the staff had not been notified to the Commission. It was also noted that an incident involving the collision of the service’s vehicle had not been recorded in the accident book nor had it been reported to the CSCI. The manager was not even aware of this incident and the Inspector is concerned that there is poor communication between staff and the management team, which is not to the benefit and protection of the service users. Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 N/A 2 3 1 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 N/A 2 2 1 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 LIFESTYLES Standard No Score 11 N/A 12 3 13 3 14 2 15 2 16 3 17 Standard No 31 32 33 34 35 36 Score N/A N/A 3 1 1 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bells Court Score 3 2 1 N/A Standard No 37 38 39 40 41 42 43 Score 2 1 1 3 2 1 N/A DS0000059595.V266326.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5(1)(a-f) Requirement The Registered Person must ensure it provides service users and the Commission a copy of the Service User Guide. The Registered Person must ensure it undertakes a review of each service user to determine their suitability for the service. Service users care records must be updated to reflect the current needs of the service user group. The Registered Person must ensure each service user has an up to date statement terms of conditions including a breakdown of fees paid by the service user. The Registered Person must ensure service users care plans clearly set out how the needs of service users are to be met. They must provide a full picture of their daily routines. Outstanding Requirement 9 August 2005 not met. The Registered Person must ensure service users meeting minutes document action taken following any requests made by DS0000059595.V266326.R01.S.doc Timescale for action 16/01/06 2. YA3 14(1)(2) 16/01/06 3. YA5 5(1)(b)(c) 16/01/06 4. YA6 15(1)(2) 16/01/06 5. YA8 12(3) 16/01/06 Bells Court Version 5.0 Page 27 6. YA9 13(4) 7. YA10 12(4)(a) 8. YA14 16(2)(n) 9. YA16 12(3) 10. YA16 12(3) 11. YA17 16(2)(1) a service user. Any follow up must be documented at the next meeting. The Registered Person must ensure service users risk assessments and behavioural guidelines are updated to reflect any changes and how these should be addressed. The Registered Person must ensure personal details relating to service users, is only recorded on their daily notes and not in the communication book. Non care matters should only refer to service users by their initials. The Registered Person must ensure service user are given the opportunity to have individual holidays and not have to go together in one group. The Registered Person must ensure the daily recording of service users must provide more evidence of service users responses to support and activities provided. It must also refer to what kind of domestic tasks had been completed. Not Assessed. Requirement brought forward from 9 August 2005. Service users care plans must provide evidence where service users have been consulted with regard to having a key to their bedroom. Not assessed. Outstanding Requirement 8 September 2005 brought forward. The Registered Person must ensure that service users have access to menus that offer a variety of nutritious meals. 16/01/06 16/12/05 16/01/05 16/12/05 16/12/05 16/12/05 Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 28 12. YA18 12(1)(a,b) 13. YA19 12(1,a-b) (2) 13(1)(b) The Registered Person must 16/12/05 ensure that nutritional screening assessments have been completed. Outstanding Requirement. Timescale 8 September 2005 not met. The Registered Person must 16/12/05 ensure service users weight is recorded every month. Any reason why this has not been done must be documented. The Registered Person must ensure all service users are offered and arrangements are made for the treatment from dentist, optician and chiropodist. Each service user must have an individual Health Action Plan in line with the D.O.H. Guidance Valuing People. The Registered Person must ensure that medication quantity and dosage of medication received is booked in onto the Medicines Administration Records (MAR Charts). Outstanding Requirement. Timescale 8 September 2005 not met. The Registered Person must ensure all service users have up to date written protocols for the use of PRN medication. The medication procedure must be amended to include that any medication errors must be reported to the CSCI. It must also have details of the supplying pharmacist. Outstanding Requirement. Timescale 8 September 2005 not met. The Registered Person must ensure that any medication prescribed midway through the DS0000059595.V266326.R01.S.doc 14. YA19 12(1,a-b) (2) 13(1)(b) 16/12/05 15. YA20 13(2) 16/12/05 16. YA20 13(2) 16/12/05 17. YA20 13(2) 16/12/05 18. YA20 13(2) 16/11/05 Bells Court Version 5.0 Page 29 19. YA20 13(2) 20. YA20 13(2) 21. YA20 13(2) 22. YA20 13(2) 23. YA22 22(1) 24. YA23 13(6) 25. YA23 13(6) MAR chart cycle is documented on the MAR chart. Any unused medication must be returned to the supplying pharmacist. The Registered Person must ensure each service user has a protocol agreed with their GP for the administration of Homely Remedies. The Registered Manager is to undertake a drug audit of all staff administering medication and any discrepancies must be addressed. The Registered Person must ensure staff signs on the MAR sheets when medication has been administered. The Registered Person must ensure all staff undertakes the Safe Handling of Medicines accredited training. The complaints procedure must be amended to state that the CSCI can be contacted at anytime during the complaints process and provide assurance that no one will be victimised for making a complaint. Copy to be forwarded to the CSCI. Outstanding Requirement. Timescale 8 September 2005 not met. The Registered Person must ensure that the adult protection policy and procedure refers to organisations who provide support to service users and an outline of training available to staff. Outstanding Requirement. Timescale 8 September 2005 not met. The Registered Person must ensure all staff receives training in adult protection. Two signatures are required for all transactions with regard to the DS0000059595.V266326.R01.S.doc 16/01/06 16/01/06 16/01/06 16/01/06 16/01/06 16/01/06 16/01/06 Bells Court Version 5.0 Page 30 26. A30 13(4) 27. YA33 18(1)(a) 28. YA34 19(1,a) (2,b) 2,7(a) 29. YA34 19(1)(a) (b) 2,7(a) 30. YA35 18(1)(c)(i) 31. YA35 18(1)(c)(i) management of service users’ personal allowances The Registered Person must ensure disposable towels are provided for the kitchen and bathroom. Bars of soaps and towels must be removed in order to reduce risk of cross infection. The Registered Person must ensure the staff rota clearly states the shifts covered by staff. Full names of staff are required. The Registered Person must ensure staff recruitment records include all the required documentation as required in Schedules 2 & 4 Care Homes Regulations 2001. Copies of letters requesting references must be on file. The Registered Person must ensure staff recruitment records provide evidence of CRB applications and outcome of CRB applications. Outstanding Requirement. Timescale 8 September 2005 not met. The Registered Person must ensure all staff receive updated training in the flowing mandatory topics: - First Aid - Infection Control - Food Hygiene - Fire Safety - Health & Safety - Adult Protection All new staff must have a full induction programme. A training Matrix must be developed that identifies future training needs. The Registered Person must ensure staff receive training in the following: DS0000059595.V266326.R01.S.doc 16/01/06 16/01/06 16/01/06 16/12/05 16/01/06 16/01/06 Bells Court Version 5.0 Page 31 32. 33. YA36 YA37 18(2) 9(1)(2)(b) (ii) 34. YA42 13(4) 37(1) 35. YA42 13(4) 36. YA42 13(4) 37. 38. 39. YA42 YA42 YA42 13(4) 23(4)(c)(v) 13(4) 23(4)(c)(v) 13(4) 23(4)(d) 13(4) 23(4)(a) 40. YA42 - Physical Intervention - Autism - Challenging Behaviour - Epilepsy - Forensics The Registered Person must ensure staff receives supervision every two months. The Registered Manager must ensure that he ceases working for his previous employer and concentrate on the management of this service. The Registered Person must ensure that CSCI is notified of all issues in relation to Regulation 37. Outstanding Requirement. Timescale 8 September 2005 not met. The Registered Person must ensure product data sheets are in place for all materials used and stored in the home under COSSH Regulations. The Registered Person must ensure any accidents in the care home are recorded in the accident book. The Registered Person must ensure the emergency lighting is tested every month. The Registered Person must ensure the fire alarm is tested every week. The Registered Person must ensure all staff receives fire safety training. This is now overdue. The Registered Person must ensure there is a risk assessment in place for the prevention of fire. 16/01/06 30/11/05 17/11/05 16/12/05 16/11/05 16/12/05 16/12/05 22/11/05 16/12/05 Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 32 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bells Court DS0000059595.V266326.R01.S.doc Version 5.0 Page 33 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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