Inspection on 15/07/08 for Bethany Lodge

This inspection was carried out on 15th July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bethany Lodge 05/11/08

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 27/09/2008.

CARE HOME ADULTS 18-65 Bethany Lodge 222 Malvern Road Worcester WR2 4PA Lead Inspector Jean Littler Key Unannounced Inspection 15th July 2008 10:00 Bethany Lodge DS0000071649.V367590.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 Bethany Lodge DS0000071649.V367590.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. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethany Lodge Address 222 Malvern Road Worcester WR2 4PA 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) 01905 420088 01905 420402 manager.bethanylodge@tracscare.co.uk suehullin@tracscare.co.uk Tracscare Group Ltd Vacant. Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) 8. The maximum number of service users to be accommodated is 8. This is the first inspection of the service since Tracscare Group Ltd. was registered. Date of last inspection Brief Description of the Service: Bethany Lodge was registered by the Commission (CSCI) on 16 April 2004. In April 06 the service was purchased by the Tracscare Group who own a number of residential care homes in England and Wales. The group continued to operate the service under the company Bethany Lodge Ltd. but introduced Tracscare policies and procedures. The company registered with the Commission later changed from Bethany Lodge Ltd to Tracscare Group Ltd. in March 2008. The house is situated on the outskirts of Worcester on a main road in a residential area. It is close to all the facilities in Worcester city and close to link roads to other towns in the region. The service provides residential, personal and social care for up to eight younger adults who have a learning disability with a primary diagnosis of Autistic Spectrum Disorder. All but one of the bedrooms are on the first floor, which is accessed by the stairs, so the majority of service users must be able to use the stairs. Each person has their own single en-suite bedroom. On the ground floor there is a lounge, a dining room, kitchen, sensory room, jacuzzi, small laundry and a private garden. The company have information about the Home that can be sent out to interested parties and there is also a web site. A copy of the Service User’s Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 5 Guide could not be found in the Home so the current fees and additional charges could not be established. It was not established if the fees are included in the Guide and therefore available to the public as required by the regulations. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. We (the Commission) carried out an inspection over seven hours. We looked around the house and spoke with four of the staff. The manager, Mrs Ferguson, was not there so we spoke to her after the visit. She had given also us written information about the home before we came. One man let us see his bedroom. The way people spent their time and how staff supported them was watched over five hours. Some records were looked at such as care plans and medication. One person completed a survey with staff support. Other people were not able to give their views in this way. Surveys also went to people’s families, staff and some professionals. Two families, two staff and one professional replied. What the service does well: The house is near the town centre. The house is quite homely; people have nice bedrooms and their own bathrooms. People are being supported with their personal care needs and assisted to have their own image and clothes they like. People enjoy the meals provided. People are supported to take part in activities they enjoy and go out regularly. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 7 Proper checks are carried out on people who want to work at the Home. What has improved since the last inspection? What they could do better: The way people are assessed and offered a place at the home should be improved. The needs and views of people already living in the home should be better considered. People’s support and safety needs should be written in their care plan and reviewed at least every six months. All staff should read and follow these instructions. People need to have clear plans in place to show how are being enabled to stay healthy and supported when they have a health problem. The way people’s tablets are looked after should be improved to help stop any mistakes. People should be provided with a garden that is nicely planted and looked after. There needs to be more staff on duty in the day to make sure people have the support they need without waiting and can follow their chosen routines and activity plans. Staff should always be awake at night unless it is shown that people do not need this support. Staff need to support people in a consistent and respectful manner. Staff must not take away people’s rights unless this is agreed and is in their best interest. People need to be supported by a staff team who are better trained and more closely supervised. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 8 Records can be clearer to help to protect people. The home needs to be run in a way that puts more importance on their safety and wellbeing. 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. Bethany Lodge DS0000071649.V367590.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 Bethany Lodge DS0000071649.V367590.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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Prospective service users and their representatives cannot be confident that they will be provided with all the necessary information and given enough opportunity to trial the service. A prospective service user cannot be confident that their assessed needs and their suitability to live with the others will be carefully considered before their admission. They cannot be assured that staffing arrangements will be sufficient and that staff will be made aware of and trained in how to meet their needs. EVIDENCE: Mrs Ferguson reported in the Annual Quality Assurance Assessment (AQAA), ‘A care plan is developed prior to admission of a service user from a very detailed assessment and this is reviewed and updated regularly. Detailed reactive management plans and risk assessments are developed utilising clinical services. Tailored clinical training packs are developed and training days are scheduled. Introductory visits are carried out effectively and the outcome documented. A detailed thirteen-week review is held with all interested parties. At Bethany Lodge prior to admission we like to arrange a transitional period whereby the identified key worker works with the prospective service user in their environment enabling them to get to know each other prior to admission’. One person has left since the last inspection and another moved in during March 08. There is one vacancy. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 11 Just prior to her leaving, the previous manager had reported to us that a man was being admitted to the home who she felt, after seeing written information about his needs, would not be compatible with the current service users. The assessment of his needs was carried out by the area director, however, this was not in his file during the inspection. The man was admitted during the time when there was no manager and the same week as the deputy was leaving. During a telephone discussion following the inspection Mrs Ferguson said the man had been admitted just prior to her starting in post so she was not sure of everything that happened. She said the company assessor had completed an assessment of his needs. This had not been seen during the inspection because it had been mislaid and she had found it the following day. She said he had come for a day visit with a worker from his previous placement, who is now his advocate. She did not know why he had not stayed overnight or visited more often. She was unaware if any of the people living in the home had been consulted about this man moving in after they had met him. This man’s file showed no evidence that he or his representatives had been given a copy of the home’s Service User’s Guide or been asked to sign a copy of the Terms and Conditions of Residency. The file did not contain any information from his last care service even though he had lived there for three years. It contained no details of whether he was on a trial stay but his previous home had already closed. A copy of the assessment was provided following the inspection. This covered many areas and set out his main needs briefly but clearly. It included the following: - ‘This person will require a home for people with a severe learning disability. The staff team will have to be trained and skilled in working with adults who have a severe learning disability and challenging behaviour. Tracsacre staff are trained and have a working knowledge in the management of challenging behaviour through low arousal and non-confrontational techniques. It will also be imperative that staff have expertise in the safe management/support of epilepsy’. A care plan was seen that had been written by the manager of another service at the time of this man’s admission. Parts of this did not reflect the man it was about or the assessment information, for example it said he had a mild learning disability, autism and obsessive-compulsive disorder. It referred to his need to have discussions with a keyworker regularly to discuss and express his feelings. The man has no speech and communicates through his behaviours. A worker was asked about the contradictory information. She did not seem to have read the care plan before and said it did not make sense to her. The majority of the staff team are new and lack experience of supporting people with these high needs. No epilepsy training has been provided and many have no challenging behaviour training. This could mean that staff are unable to respond appropriately to incidents that occur and therefore people could be at risk. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 12 Mrs Ferguson reported that she was intending to review the man’s care plan after the 13 week placement review. This was due in June but was overdue and had been now planned for August. A ‘reactive management plan’ had been completed, which contained guidance about how staff should respond if he becomes distressed and self-harms. It is not a comprehensive reflection of his needs e.g. his continence, mobility and safety needs, yet this is what was available to the new staff and agency staff. In previous inspection reports staffing levels were confirmed as being six staff for seven service users. Mrs Ferguson reported that five staff had been the usual levels on each shift when she took over. At this time one woman was unwell and was being cared for in a nursing home and the new man had just been admitted. Since then staffing levels have been reduced on many occasions to four and waking night staff have not been consistently provided. The new man has higher support needs than the service user who left. His assessment confirmed he needs his epilepsy monitoring at night and he often gets up at 5.30am. Mrs Ferguson confirmed that she did not change the staffing levels and arrangements to reflect this. A complaint was received by the Commission prior to the inspection. Part of the information given related to concerns about this man’s admission. They included how low staffing levels were affecting other people in the home as this man often needs two staff to support him and he has been assessed as needing one to one support; staffing difficulties in the home mean inexperienced and new staff are having to support this man and be responsible for responding to his epilepsy and self-harming behaviours without training and with little support. We found that these comments did reflect the situation at the home. Incident reports and other records showed that the admission of this man had been one of the triggers in a current service user becoming more anxious. His routine of waking at 5.30am had impacted on her already disturbed sleep pattern. During one incident she bit this man. She has recently been prescribed regular medication again for her behaviours. Mrs Ferguson confirmed that the man’s admission had had a negative impact on this woman’s life. Staff reported that access to the kitchen is now restricted to all service users because it is kept locked to meet this man’s safety needs. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 13 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, 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. People using the service cannot be confident that their changing needs are accurately reflected in their care plans. People are not being properly safeguarded, as some of the risks they are taking have not been assessed. They are being enabled to make some choices but some decisions are being made for them without justification or proper recording. EVIDENCE: Mrs Ferguson reported in the AQAA that in this area they do the following well, ‘Care planning, financial assessment, respect rights of clients, financial record keeping, risk assessment, record keeping and confidentiality’.. One of the staff who had been in post for six months struggled to locate the care plans when asked and said that staff do not use these as they are being retyped. There was no evidence in the plans that staff had read them. As mentioned already the care information for the newest service user did not provide staff with clear and accurate information about his needs. For example there was no falls assessment although he has an unsteady gait and a history of tripping up, none regarding how he should be supported to safely access his Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 14 bath even through his en-suite had been deemed unsuitable and is being changed and none regarding his epilepsy. Another record indicated he was at risk from climbing the stairs and a barrier was going to be purchased. No risk assessment was found and no barrier seen. A second care plan was seen. This had not been written in April 07. It was not clear who had been consulted during the process and was not in a format the service user would understand. There was no indication it had been reviewed. The finance section still said her money was in the process of being transferred as part of her move into the home. Risk assessments were in place covering sharp objects and access to the kitchen. One section stated she had in the past left buildings alone and is at risk in the community if alone. The action stated that the front gate must be locked at all times. The gate had a notice on it saying it must be kept shut but was wide open all day. A professionals report from 2007 stated that she said dislikes bells but has built up a tolerance. A weekly alarm test was due on the inspection day. The worker planned to do this after this person’s outing so her upset did not prevent the outing. When asked why the woman had to be present if she was currently unsettled the worker was unsure. There was nothing in her care plan to guide them about this. In the end he held the test while she was out. The only review meeting report on file was from May 07 not long after she had moved in. This showed she had settled well after four initial incidents and the aim was to withdraw the need for regular medication for anxiety related behaviours. This had been achieved in 2007. The reactive management plan from April 07 had been reviewed in June 08. This said that one to one staffing is required, a well-organised activities programme and symbols on her chart so she knows the routine for that day. Staff reported that symbols are not being used currently as they did not have the board they needed. She was being provided with one to one support but she was taken out by a worker who had been in post for just six weeks. Staff meeting minutes indicated that her routine was not always being followed. Reports seen showed that aggressive incidents had started again in recent weeks and people had been bitten and punched. The medication for behaviours had unfortunately been reintroduced. A third care plan was sampled to see if there was a risk assessment about road safety in the community. Two incident reports noted that the woman had run across a main road during an outing. None was found. A fourth was sampled to see if their was a best interest decision recorded guiding staff to limit the amount of time the man spends in his bedroom. Staff were observed to stop him accessing his bedroom in the morning. None was found. This is a form of restraint and should not take place unless there a clear risks to him and he does not have the capacity to decide where he spends his time. Other information and observations indicated that people were being supported to make some decisions for themselves e.g. one care plan said the person should decide what clothes to wear. Staff supported another person to decide what to buy at the shops with their own money. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The people using the service are being offered a variety of appropriate activities and are accessing local community facilities but poor staffing arrangements are affecting these. They are not being well supported in personal development. Their rights are not always being respected and they are not always being supported to stay in contact with their families. A reasonable varied of meals are being provided and mealtimes are relaxed. EVIDENCE: Only one of the four care plans sampled contained personal goals. These were not set out so progress could be measured e.g. develop independence skills. Some related to action staff were to take e.g. open a bank account, consider if any college courses would be suitable. Each person seemed to have their own daily routine but in some cases people were having to wait for the support they needed due to the staffing levels. A worker reported that sometimes activities are cancelled due to staffing levels. One woman’s haircut was cancelled on the day of the inspection. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 16 As mentioned one man was being kept out of his bedroom in the morning. A worker reported that this was for his own benefit, as he needs to mix with others and not spend all the time watching his television. He was not offered any items of stimulation during the two hours he was observed until we asked a worker about this. Two baby toys were then given to him, which he engaged with and smiled for ten minutes. The television was on quite loudly in the morning and the radio after that. The programmes on did not seem appropriate and no consultation with service users in the room was observed. Service users were offered outings e.g. one went for a walk twice, one went to the shops and two went swimming. A group spend time in the garden and trampoline and swinging lounger were both used. One service user’s assessment said he likes water play, swimming and films. He had a weekly activity timetable but these were not included on it. The assessment said he liked the jacuzzi and spa and these were being offered. Some of the activities on his plan for that day were offered such e.g. a walk. Others were not seen e.g. the tactile book. All but one service user has family involved and most go on family visits quite regularly. Two families gave feedback. One said they were not getting their weekly call anymore. Both families reported that they do not know the staff team now. A professional reported that families and professionals are no longer well informed and gave the example that the organisation had not communicated about the manager and staff team changes. Food is purchased in local supermarkets. The service users are involved with the shopping, however, some only buy a few items as they would not benefit from being involved with a large weekly shop. The menu file was untidy and only two of the four weekly menus were located. These showed a varied diet but only one choice per meal. Individual records of what people had eaten were not seen in the daily recording system to demonstrate that alternatives had been offered when require. A member of staff said the food was good and that Mrs Ferguson had arranged for the meat to come from a local butcher so it was now better quality. Staff reported that the quality of the food is now excellent. Staff eat with the service users. A lunch of homemade soup seemed calm and relaxed. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The people using the service cannot be confident that they will be consistently supported in the way they prefer and benefit from. There are risks that their health needs will not be met in a timely manner and that their medication will not be safely managed. EVIDENCE: People in the home looked well presented and had their own personalised styles. The care plans sampled did not contain clear detailed information about how people prefer to be supported with their personal care needs to promote consistency. Charts were in place to evidence what support had been provided. Those seen for June contained gaps of up to a week but daily records did confirm that daily care was being provided. Staff were observed to support people regularly with going to the toilet and seemed to have set routines e.g. every hour or two hours. Staff did discuss people’s personal care with each other in front of them and other service users e.g. announcing the results of someone visiting the toilet. One was observed to tell a service user in quite a firm way, that she would not go out to the shops if she was silly. As stated another was prevented from accessing his bedroom in the morning. Other interactions observed were gentle and caring. People were offered lots of drinks and sun cream was applied in the garden. The arrangements for clinical Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 18 waste mean staff walk through communal areas with waste bags after assisting someone to change. This does not help maintain their dignity. One family reported that clothes are being lost and damaged regularly e.g. shrunk. Mrs Ferguson reported in the AQAA, ‘Care plans contain detail of how a client should be supported with personal care. A detailed policy on support with personal care is in place. Care plans contain details of all general and specific health care needs and in addition a health care action plan is drawn up for clients with learning disabilities. All medical appointments are documented and any follow up appointments are noted’. Health Action plans were seen in both care plans sampled. One was blank and the other was only partially complete. Health appointment records for one man showed he had been to the GP for a urine and blood test in June but there was no information as to why. Another person had been to the opticians in May 07 and records showed she was due to go back in a year. There was no record that she had been back in May 08. The new man’s care plan said he would need clinical input each month from the company clinical support nurse. There was no record on his file of this being provided. A person making a complaint to us reported that this man was self harming to a high level and that he had caused himself to have a bad cut to his head but due to staff inexperience he was not taken to the doctors for three days. Records showed he had gone to the doctor but details and the course of events could not be tracked. No accident report could be found. As mentioned the situation in the home has caused an increase in anxiety and associated behaviours for some people and one person has had to start taking medication that she had successfully withdrawn from. Risks related to epilepsy and from falls due to mobility problems had not been fully assessed. Staff had not been trained in responding to epilepsy. The medication storage and security arrangements seemed appropriate. Records showed that doses had been given that day and stocks in hand confirmed this. The chart set up for a medication that was recently prescribed could have been written more clearly. The dose changed at a certain date but a new row was not started. Her daily records said the dose should change after one week yet the change was made after two weeks. No explanation could be found for this. A stock check was undertaken to see if the instructions had been followed but it was not possible to draw a conclusion. The chart for June when the medication was started could not be located to start with but was then found in with the jacuzzi water test folder. This chart showed that 56 tablets were signed in at the start but packets indicated that at least 80 had been supplied in total. Five packets were all open and some tablets used from all. Some people are prescribed paracetamol on an ‘as needed’ basis. The protocol sheets to give staff instructions about when to administer these were blank. Only Mrs Ferguson and two staff have attended an accredited Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 19 medication course. A list of which staff have been deemed competent to give medication was not seen in the medication folder or included on the training matrix. It is positive that a witness system is used so two people are involved in all administration to reduce the risk of errors. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 20 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, 23. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. People using the service are not consistently having their views listened to and acted on. The arrangements in the home mean people cannot be confident that they are protected from abuse, neglect and self-harm. EVIDENCE: Mrs Ferguson reported in the AQAA, ‘The complaints procedure is robust. A complaints poster is displayed in each home informing clients of how they are able to complain and to whom. Compaints leaflets are posted around the home to enable any person at any time to fill one in. Complaints are analysed on a monthly basis and then collated yearly to establish any patterns for future prevention’. Mrs Ferguson said that that the staffing changes and current arrangements have meant that service users are not being supported by staff and keyworkers that they know well. It is positive that all have either family or an external advocate involved. In communication after the inspection Mrs Ferguson reported that there was no poster or leaflets in place yet but she would get them from the company. Very few of the people using the service would be able to make a complaint through a process and even then filling out a form would have to be done with help. Mrs Ferguson did not address this in the AQAA. The service user who completed a survey said she would tell the manager if she had a problem. A professional reported that the previous manager and team had always responded excellently to any concerns. She wished to reserve judgement about Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 21 how Mrs Ferguson managed issues but said she had reported a concern at the end of May and would see how it was dealt with. The complaints file in the home did not have a record of this concern. The one entry in the file related to a complaint that had been made to us. Mrs Ferguson had been informed of this once we had made a safeguarding referral to social services. This protection matter that relates to the conduct of a member of staff who is currently under investigation. The complainant said they had tried to inform Mrs Ferguson of the concerns but she had not taken them seriously. The providers reported that there was no evidence in the home to indicate this was the case and that Mrs Ferguson had always responded appropriately to in her other posts. Once the matter was raised formally Mrs Ferguson and the providers have taken action to protect people and cooperated with the local proceedures. As mentioned earlier one service user was upset that he was not being allowed into his bedroom. There was no guidance in place telling staff to restrict his access yet staff failed to see his frustration as a complaint. Another service user screamed very loudly when she was asked to leave her chosen activity to go in the mini-bus. The worker reacted quickly by apologising and left her alone. It appeared that staff felt able to restrict the man’s access to his bedroom because he showed his unhappiness in a less extreme way. The admission of a man with complex health and behaviour needs at a time when there was no management team and many staff leaving put him and others at risk. The majority of the current staff team have not had the training and guidance they need to ensure they know how to respond appropriately to peoples’ behaviours and have not had adult protection training. This along with low staffing levels and a lack of clear guidance about managing risks means the potential for neglect or abuse are quite high. Mrs Ferguson reported in the AQAA, ‘Robust procedures are in place to protect vulnerable persons from abuse and to protect the staff who report any concerns. All staff are properly checked prior to recruitment. Staff are trained at induction in dealing with challenging behaviour appropriately, prevention of abuse, disclosure of malpractice. Records are kept and audited in relation to clients money and every effort is taken to prevent theft or fraud. Following the Sutton & Merton Case we have developed a plan for preventing institutionalised practise in our homes. We have developed an audit and provided training. We are in the process of developing further tools’. Nothing was recorded in the AQAA about what needs to be improved to better safeguard people. This is of concern as it indicated that a lack of understanding about how the overall situation in the home relates to how safe people are. It also means there is no clear improvement plan in place for 2008/9. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 22 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, 25, 26, 27, 28, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People are living in a clean, comfortable and homely environment. People have personalised bedrooms and with the exception of one man their en-suite facilities meet their needs. The garden is not well maintained and some areas of infection control and fire safety need to be addressed. EVIDENCE: Fire prevention equipment is installed and Mrs Ferguson reported in the AQAA that routine checks and servicing have been carried out. There is a fire risk assessment but this was written in May 07 and stated it expired in May 08. There was no evidence that it had been reviewed. New door closure mechanisms had been recently fitted but two internal fire doors with these devices were found to be wedged open. It is positive that there are only seven service users and an eighth has not been admitted. For people with Autism sharing the same living space with seven peers and up to seven staff is not considered to be best practice. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 23 There is a large dining room and an art room so there is scope to use the living areas differently. The lounge is fitted with comfortable sofas and entertainment equipment. There is a jacuzzi room and a sensory room. Only one bedroom does not have a bath in the en-suite facility. The person using this room is the one who uses the communal bathroom nearby. This is a very plain room and consideration should be given to personalising it for the person who uses it. Staff reported that peoples’ bedrooms are locked when not in use. This means if they cannot manage or do not want to carry a key they have to ask staff to access their rooms. This is a disempowering practice. There were no risk assessments seen on the care plans files to indicate why the bedrooms needed to be kept locked. There was evidence at the last inspection that the organisations maintenance arrangements were not sufficient and that repairs were taking too long to be attended to. Mrs Ferguson did not mention in the AQAA if arrangements had improved. She did report that quotes are being obtained for the halls to be decorated. The overall impression of the environment is that it is comfortable and reasonably homely. It is positive that the sensory room has been refitted and is back in use. Two of the tables are heavily marked and some of the doors did not close freely. One family commented that the garden was a mess and the house needed redecoration. The ground floor bedroom allocated to the new man had been fitted with a double bed and suitable furniture. Some of his personal items were on display. There were some stains on the carpet that need attention. Records indicated that the bath in the en-suite does not meet his needs and a wet/shower room is needed. Mrs Ferguson said a quote is being obtained. There was no evidence that an Occupational Therapy referral had been made so advice on aides to make bathing safer could be obtained along with how the new layout would best meet his needs. The garden was again found to be unkempt. Weeds were fully grown and even around the front door, which does not create a positive impression of the service users’ home. A raised bed area at the back patio is still empty of plants with weeds growing. This area has been in this condition for two years and recommendations have been made in the last two inspection reports. Mrs Ferguson reported that quotes for a sensory garden on this area are being obtained, however delays in this have meant this is the third summer the garden has been unattractive. Records seen indicated that Mrs Ferguson expects staff to do gardening chores with the service users. This strategy does not seem effective. The house was reasonably clean although there were tea stains and crumbs in the kitchen drawers. The small laundry was untidy and some flammable material such as a quilt and a bin liner was being heated up at the back of the tumble drier. Staff reported that cleaning schedules are in place. In the afternoon an agency worker was tasked with cleaning the office, as the agency Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 24 night staff had not done this allocated duty the night before. With only five staff on duty this did not seem to be a good use of his time. Mrs Ferguson reported in the AQAA that none of the current staff have had infection control training but that this is being arranged. Hand washing facilities were in place and stocked up. Hand washing instructions were seen on the walls to remind staff. A record showed that contractors had found problems when the water in the jacuzzi was tested recently. They had recommended it was drained and disinfected. The record did not indicate if Mrs Ferguson had taken the appropriate action. She did report that she is due to attend a course on jucuzzi management soon. There has been an increase in the amount of clinical waste in recent months. Just outside the dining room patio doors in an area accessible by service users were some small sani-bins and four large full yellow sacks of clinical waste. Staff were walking through communal areas with items for disposal in semitransparent nappy-sacks. This is not very dignified for the person who has just been assisted to use the toilet. Many of the staff team are new or temporary workers. The rota and shift planner did not show that any consideration was being given to which staff had food hygiene certificates when being allocated cooking duties. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. People living at the home are not benefiting from the support of an effective, well trained and supervised staff team who know their needs. Suitable staffing levels are not always being provided. People are being protected by the recruitment practice. EVIDENCE: Only four members of staff were on duty at the start of the inspection to support the seven people using the service. For the afternoon and evening there were five. Two of the five were bank staff. As mentioned under Choice of Home previous staffing levels have been six. There has been a high turnover of staff in the last year with nine people leaving from a team of twelve. There are vacancies and two staff are currently on maternity leave. There is currently only one part time waking night worker. The gaps in the rota are being covered by bank and agency staff along with permanent staff working overtime. When no one can be found for a waking night duty two staff are sleeping in. As one man usually wakes at 5.30am the staff member sleeping in on the ground floor is expected to get up at this time. They also have a listening monitor and are expected to be aware and respond if this man has a seizure during the night. Another service user is restless at night and recently she has had a very disturbed sleep pattern. A worker said this woman had not Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 26 slept for nearly a week in June. The practice of two staff sleeping in has only been used in the past when night staff called in sick at short notice and prior to March 08 none of the service users had epilepsy. A risk assessment had not been completed to demonstrate that this change to the staffing arrangements was safe. There was evidence in the morning that although the four staff were working hard people were still waiting to have their needs met. One man was eating his breakfast at 10am. A worker had been cross about the performance of the agency night staff and reported that he had found this man in wet pyjamas when he arrived on duty at 8am. This indicated that the service user had been up for two hours before being given breakfast. One woman was due to have a haircut but the appointment was cancelled because of the staffing shortfall. Another woman was taken out for a haircut but was told repeatedly to wait beforehand and staff could not give her an actual leaving time to help her manage her anxiety. Another woman wanted confirmation about a part of her daily routine but staff could only tell her this would take place later if they had time. The reassurance provided by predictable routines and scheduled activities is often essential to people with Autism and therefore the service needs to operate around this principle. There were other indicators that staffing levels were insufficient, for example, there was little food in stock and staff were buying a few items for the meal ahead, the laundry was disorganised and some of the cleaning tasks had not been completed. Mrs Ferguson reported after the inspection that she had decided to change the staffing arrangements and would have six staff on during the day and would use agency waking night staff to cover gaps rather than two people sleeping in. Relatives reported that they were concerned about the changes in the staff team and felt these were having a negative effect on their children. They had not been kept informed of the changes so did not know who staff were when visiting. A staff photo board by the front door that was used to show service users and visitors who was on duty was not in use. The providers reported that they wrote to relatives and offered them two dates at the end of March for them to come and meet Mrs Ferguson, Mr Perks (the responsible individual) and the new staff team. They did not say if anyone had been able to attend these meetings. Mrs Ferguson submitted a training matrix following the inspection. This showed that all staff had outstanding courses to attend. Some courses had planned dates, but not all. None of the staff on duty on the day of the inspection had attended first aid or epilepsy training. Only two staff in the team have attended autism awareness even though the service is meant to specialise in autism. Only one worker has attended infection control training. She reported the following, ‘The information about the staff who were here when I arrived is somewhat limited, therefore, where staff are unable to prove with certificates, Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 27 that they have completed a course, I am putting them back on courses. With regard to induction, none of the new staff have completed yet but only one has been here 12 weeks. With regard to the old staff, some tell me they started it but didn’t complete, so they will have to complete their booklets as well’. Mrs Ferguson also reported that she has struggled to find a suitable training provider in the area but has now located one and courses are being booked. This training provider has agreed to put together an autism course. It is concerning that a specialised service has to rely on local training providers to train its staff in basic autism awareness. It is positive that the AQAA indicated six staff have an NVQ qualification in care. Others will need to be supported to gain an award after completing their foundation courses. Evidence earlier in the report demonstrates that some staff are not working in line with good practice principles. Some interactions seen were caring and sensitive. They did not have clear care planning guidance available to help them. This new staff team is not yet working effectively and being supported to provide a consistent support to service users. The company has a policy to provide supervision sessions at least every two months but obviously new staff need more support. One worker reported in the survey that she had been in post over six months but had only had one meeting with the manager. Staff meeting minutes did not reflect those of a professional specialised service. One entry was, ‘Service user_ _needs to be respected and loved until she kicks off’. At one meeting it appeared the manager had not been present but a behaviour intervention strategy for one woman had been agreed by the care staff. The entry was, ‘Idea to send service user_ _to the dining room to calm down, type it up and hand it out’. There was nothing to show that staff who were not present had read these minutes. Recruitment records were not accessible as Mrs Ferguson was not present and they are stored securely. She reported in the AQAA that robust recruitment procedures are being implemented. Staff surveys indicated that checks had been carried out before workers took up their post. The providers reported that Mrs Ferguson found that paperwork relating to the recruitment of new staff had not been sent off by the previous manager causing a delay in the recruitment of new staff compounding the staffing difficulties. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 28 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, 40, 41, 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The people using the service are not benefiting from a well-run service. The change in the homes’ management and staff team have impacted negatively on their daily lives. They are not being fully safeguarded by the way the service is being operated. EVIDENCE: The ownership of the service changed when the Tracscare Group Ltd. were registered as the providers in March 08 instead of Bethany Lodge Ltd. Although the directors of both companies are the same the service is new and this is the therefore the first inspection of this service. The management arrangements in the Home changed in March when the manager and deputy both left. Mrs Ferguson started in post on March 19th 2008. She reported that she has five years experience of care work and has been a manager before. She gained the Registered Managers Award and NVQ4 in Care in 2007. She said she has not applied to be registered and did not intend to until the home Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 29 had been sorted out. She was informed that as she is managing the service she must apply for registration without delay, as it is a legal requirement. It is the legal responsibility of the providers of this service to ensure this happens. The company have support staff in various departments e.g. finance, human resources and training. They have an established quality assurance (QA) process that includes monthly audits. As Mrs Ferguson was not at the service during the inspection it was not possible to review these systems. A Health and Safety audit was found that had been carried out for June. Limitations in the effectiveness of the system to highlight shortfalls and trigger action were reported on at the last inspection in areas such as grounds maintenance. There was no evidence that proactive planning had improved. The AQAA was submitted to us mid May when Mrs Ferguson had been in post for two months. The company provides managers with some corporate content that they should then adapt for their service. Mrs Ferguson had not made the AQAA reflect the current situation at the home and a lot of the information was not factually accurate when tested against the records in the home. In many areas of the AQAA there were no action points for the coming year. It is concerning that no improvement plan is in place to demonstrate that the manager and providers are clear about how to improve the outcomes for service users. The company have not provided Mrs Ferguson with additional resources to assist her to make the service safe as quickly as possible e.g. administrative, training and management support. She is working mainly office hours, which must limit the time she can spend role modelling good practice to her new staff team. She described the current record keeping as chaotic. The way Mrs Ferguson is prioritising seemed questionable, for example, both she and the deputy are due to attend a course on jacuzzi management and the deputy and other new staff are spending time working at other Tracs services to learn the company procedures. This is at a time when staffing levels are severely stretched and accurate care plans and risk assessments are not in place. Mrs Ferguson had not reported to us incidents, in line with regulation 37, where people had been hurt or put at risk. The providers have a legal responsibility to ensure such incidents are reported without delay. As mentioned, clear and up to date care guidance is not in place for staff to follow. The policies and procedures file was seen in the office but a worker had last signed this as read in April 08 indicating that other new staff were had not seen these. None of the staff on duty considered that they were in charge of the shift. Staff initially could not locate the visitors’ book and another struggled to provide care plans. It was not possible to review the management of people’s personal money, as the staff on duty did not have access to the tins. A member of staff had to use petty cash for a woman who was going for a haircut as all the bank withdrawal slips were also locked away. The inventory for a woman who Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 30 moved in a year ago had not been updated since then. A receipt indicated that a new mattress had been purchased for the new man’s bed but it was not possible to establish if this was his or if the company had purchased it. Feedback from a professional indicated that the company had not communicated appropriately about the change in management and staff at the service. The person had found out about the changes herself a month later and felt this did not reflect well on the organisation. Relatives reported to be worried about the change in manager and the high staff turnover. One thought Mrs Ferguson seemed to be trying hard and had brought in some good ideas about accessing the community. Concerns relating to health and safety have been highlighted throughout this report. These include the lack of risk assessing of people’s care needs, gaps in staff training and fire safety arrangements. Routine testing of equipment was being carried out. Mrs Ferguson and the new deputy had clearly taken over managing the service at a difficult time and had a challenging task in trying to provide continuity of care. The providers reported that initial enquiries indicate that the previous manager may have removed care records and archived others unnecessarily prior to her leaving post. It is positive that the providers have acknowledged that they were not open with external agencies and stakeholders about the situation and they could have done more to provide guidance and support to the management team. They have also committed to considering more carefully admitting new people into services that are in a state of transition. Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 1 4 1 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 2 30 2 STAFFING Standard No Score 31 x 32 1 33 1 34 3 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 2 x LIFESTYLES Standard No Score 11 2 12 3 13 2 14 3 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 1 x 2 2 1 1 x Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 32 NA Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 YA3 YA4 Regulation 14 (1) (C) Requirement The registered person must not provide accommodation to a service user unless there has been appropriate consultation with the service user or their representative regarding the assessment and the ability of the home to meet their needs. Placements must be in people’s best interest and the needs of current service users considered. 2 YA33 18 (1) (a) The registered person must ensure, having regard for the size of the home, the statement of purpose and the number of service users ensure that at all times there are suitably qualified, competent and experienced persons working at the home in such numbers as are appropriate for the health and welfare of service users to ensure their assessed needs are consistently met. The registered person must ensure that service users are not the subject of restraint unless on DS0000071649.V367590.R01.S.doc Timescale for action 31/07/08 31/07/08 3 YA7 YA16 13 (7) 31/07/08 Bethany Lodge Version 5.2 Page 33 the basis of a risk assessment. In this case this relates to a service user being prevented from accessing his own bedroom by staff locking the room and refusing to unlock it on his request. 4 YA43 37 (1) (2) The registered person must ensure the service is operated openly and that the Commission is notified appropriately of events in the home in line with the current guidance issued by the Commission to help protect the people living in the home. The registered person must, after appropriate consultation, prepare a written care plan about how each person’s support and health needs will be met. These should include information about how people are being supported to develop. The plans must be kept under review. The registered person must ensure that activities service users participate in are so far as reasonably practicable free from avoidable risks. Unnecessary risks to their health and safety in all areas must be identified and so far as possible eliminated to help ensure their wellbeing. 7 YA23 12 (1) (a) (b)13 (6) The registered person must 31/08/08 ensure that effective adult protection measures are implemented and the vulnerable service users are protected against harm. 31/08/08 31/07/08 5 YA6 15 (1) (2) 31/08/08 6 YA19 13 (4) 31/08/08 8 YA32 18 (1) (c) The registered person must (2) (a) (b) ensure, having regard for the DS0000071649.V367590.R01.S.doc Bethany Lodge Version 5.2 Page 34 size of the home, the statement of purpose and the number of service users ensure that the persons employed to work in the home are appropriately supervised and receive a structured induction. For the duration of their induction an appropriately qualified and experienced member of staff is appointed to supervise the new worker and as far as is reasonably practicable they are on duty at the same time. The new worker should not escort service users away from the care home unless they are accompanied by such a worker. 9 YA35 18 (1) (C) The registered person must ensure, having regard for the size of the home, the statement of purpose and the number of service users ensure that the persons employed to work at the home receive training appropriate to the work they perform. The registered person must ensure the person managing the home applies to be registered with the Commission. 31/10/08 10 YA37 Section (11) of the Care Standards Act 2000. 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations Revise the statement of purpose to reflect the decision to DS0000071649.V367590.R01.S.doc Version 5.2 Page 35 Bethany Lodge admit someone who does not have a diagnosis of Autism Spectrum Disorder. A copy of this must be forwarded to the Commission in line with regulation 4. 2 3 YA7 Develop accessible information and use this consistently to communicate meaningfully with the service users. Ensure decisions that are made on any service user’s behalf, when they lack capacity, are documented to evidence that they are in the person’s best interest in line with the Mental Capacity Act. Priority should be given to ensuring service users are supported to follow preferred daily routines and person centred activity programmes. Ensure agreed contact arrangements with service users’ families are maintained. Communicate more effectively with families to ensure they are informed about changes in the service. 6 YA18 Staff need to be aware of not compromising service users’ dignity when assisting them and communicating with colleagues. Health action plans should be fully completed to demonstrate the person’s needs and the plan for the year ahead. The information should cross-reference with entries about health concerns and appointments to form an audit trail. An audit trail should be clear for all medication received into the building. Hand written instructions should be very clear and a new recording row started when a change is actioned. Clear guidance should be in place for all ‘as required’ medications. Company policies regarding complaints should be implemented and any concerns/complaints raised should be recorded to demonstrate that these are acted upon. Review the practice of locking service user’s bedroom doors if their possessions are not at risk and they cannot manage the key themselves. Review the fire risk assessment and give consideration to DS0000071649.V367590.R01.S.doc Version 5.2 Page 36 YA7 YA9 4 YA13 5 YA15 7 YA19 8 YA20 9 YA22 10 YA24 11 YA24 Bethany Lodge YA42 12 YA24 YA42 the needs of the service users who have moved in since it was written. Fire doors should be adjusted to ensure they close fully and freely. Tidy the laundry and ensure items are not allowed to heat up next to the tumble drier. 13 14 15 YA20 YA24 YA29 Ensure clear guidance is in place about when staff should give any ‘as required’ medication. Provide service users with a nice garden and then ensure an effective gardening service is maintained. Provide a barrier to the stairs that other service users can operate if the risk assessment for one man indicates this is needed for his safety. Review the management of clinical waste to improve infection control arrangements and to better protect service users’ dignity. While training is being provided to newer staff demonstrate in rota planning that consideration has been given to which staff have which training e.g. food hygiene, epilepsy and first aid training. The manager should apply to be registered promptly in line with the requirements of the Care Standards Act. The manager should review the way the service is being managed and ensure effective prioritisation to help safeguard service users during this difficult period. 16 YA30 17 YA33 18 YA37 19 20 YA41 Record keeping systems should be improved and records reliably maintained to help protect service users. All staff should be made aware of the new fire door closure mechanisms and the practice of wedging doors open stopped. YA42 Bethany Lodge DS0000071649.V367590.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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