Inspection on 22/11/05 for Bevis House

This inspection was carried out on 22nd 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 42 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bevis House 09/06/08

Bevis House 25/04/07

Bevis House 08/06/06

Bevis House 29/07/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Bevis House 5 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QF Lead Inspector Alison Ridge Unannounced Inspection 22nd November 2005 10:00 Bevis House DS0000062630.V266148.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 Bevis House DS0000062630.V266148.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. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bevis House Address 5 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QF 0121 444 2184 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) South Birmingham Primary Care Trust Family Housing Association Limited Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That an application for a registered manager is received by the CSCI by 30 September 2005. The six requirements made in relation to the maintenance and decoration of the home are met by 31 July 2005. The home can accommodate six people with a learning disability under 65 years. A plan to recruit to the staffing vacancies must be recruited to by 31 May 2005. 29th July 2005 Date of last inspection Brief Description of the Service: Bevis House was purpose built as a care home, on the site of what was previously Monyhull Hospital. This was the first inspection of the home in its own right, as it had previously been registered as one of a cluster of six homes. South Birmingham Primary Care (NHS) Trust manages the staff and the home and Family Care Housing Association owns the premises. At present the home accomodates six men. The men all have a Learning Disability, some have impaired mobility, and some have some behaviours that challenge. The accomodation comprises of six single bedrooms, a communal lounge, dining room, a w.c, supported bathroom, shower room, kitchen and laundry room. The home has a garden at the rear, with garden furniture and shade. The home has recently recruited a manager, and the CSCI is awaiting an application for registration. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook most of this inspection over one day. A second visit was made to the home on December 1st 2005 to look at staffing records. Information used in the report was gathered by talking with the men who live in the home, and observing the care and support they received. Records about staffing, care and health and safety were assessed. A tour of the premises was undertaken. A member of staff and a student nurse were interviewed, and the senior carer on duty provided some further information. Comment cards were received from the men who live in the home, relatives and some of the healthcare professionals who support the men’s care. The inspectors have been seriously concerned regarding this home in the past. It was noted that work to address many of the previously raised issues had been started. The CSCI remain very concerned about the welfare of the men that live at Bevis House, in particular regarding safety, the number and competence of staff that support the men, and the large number of unmet requirements. The home has breached three conditions of registration. Despite meeting with the provider following the last inspection, no action towards addressing this has been undertaken. Failure to comply with conditions of registration is an offence, and liable to prosecution under section 24 of the Care Standards Act. Action must be taken by the provider to avoid the CSCI considering or taking enforcement action. The inspector recommends this report be read alongside the report of the previous inspection undertaken in July2005. What the service does well: What has improved since the last inspection? The people who live in the home had been supported to purchase and wear some new clothes. The men all looked well dressed and comfortable in the clothes and shoes they were wearing. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 6 People had been supported to wash, shower or shave as they preferred, and the men looked fresh and clean. The men now have their own toiletries and towels to undertake personal care with. This is a big improvement from the last inspection. Staff had undertaken a lot of work planning care, and developing risk assessments. These continue to require significant work, but are a big improvement on records of care previously held. Staff had supported the men to attend healthcare appointments, and it was pleasing to find that all routine and specific tests and appointments had been undertaken. Food hygiene practice had improved. All but one foods stored in the kitchen were all in date, and stored properly. Staff had received some training, and some was ongoing. This had been provided in the areas of Adult Protection and Communication. It was identified that more training is required to ensure staff are up to date, and have the skills to meet the needs of the men who live at Bevis House. Staff had sorted out the men’s bank accounts, and it was reported they now have access to their money. Health and safety tests had improved. The fire alarm and emergency lights had been tested, and the men and staff had practiced what to do in the event of a fire. Checks were being made on the hot water to ensure it won’t burn the men. What they could do better: The home is still very short of staff. Bank and agency staff are being used to ensure enough staff are on duty. The staff don’t always know about the needs of these specific men, or have the experience and knowledge to meet their needs. There is not enough staff that can drive the homes vehicle, which limits the number of times people can go out. The number of staff on duty is not enough to enable people to go out very often. The men who live at Bevis House need a lot of staff support to access the community, and the number and skill mix of staff isn’t enough to achieve this. The inspectors did not find the number of staff to be at a safe level when staff have breaks, or if they have to support another home. The home urgently needs to be decorated, and to have some new furniture. The existing furniture is broken and lounge furniture smells. The walls in most rooms need decorating, and in some rooms the flooring needs to be cleaned or replaced. During the inspection the home was cold. It must be kept at a suitable temperature for the men. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 7 The care plans have got better, but they still do not address all the men’s needs. During the inspection concerns about stoma care, epilepsy, and using transport were identified as areas needing to be addressed urgently. The staff need to support people develop plans about their lives, and aspirations, not just clinical needs. These could be Person Centred Plans. There are a high number of incidents where one man who lives in the home hits or shouts at another of the men, or a member of staff. In October the CSCI was told this happened ten times. The acting manager has brought this to the attention of all the right people, and undertaken some work to try and stop it occurring. This number of incidents is still too high. It was not apparent the organisation was doing everything possible to change this situation. Records about the men need to show how they have been involved in writing and developing them. The men also need to be included further in the running of the home. Staff must make sure they protect the dignity of people living in the home. An incident where a service user was left undressed in a room with the door open was observed when inspectors arrived at the home. The way the men spend their money must be reviewed. Inspectors did not find it acceptable that the men had paid for meals for the staff, or for each other when they go out. The transport arrangements do not offer good value, as the men pay towards the use of a bus, but drivers are not always available, so they have to pay again for a taxi. 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. Bevis House DS0000062630.V266148.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 Bevis House DS0000062630.V266148.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): X These standards were not assessed. EVIDENCE: The home has a stable service user group, and at the time of inspection there were no residential vacancies. These standards were not assessed. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 10 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): 6,7,8,9 and 10 Care documents and risk assessments are improving. They better reflect the needs of the men accommodated. Further work is required to service users have all their needs planned, and they are met in the way they prefer. Records were securely held. One breach of a service users dignity was observed. EVIDENCE: The plan of one service user was assessed in full, and further files were sampled. The care records showed that a lot of work had been undertaken developing records of care that inform staff of the persons needs, and how these are to be met. The plans had been recently developed. The plans assessed were very personalised, but they did not show how the author had consulted or involved the individual in the process, or how they knew this was the way the person wished their needs to be met. To date the plans contain details about clinical needs, and contain no element of life planning or goal setting. Staff had undertaken regular meetings with service users to discuss their satisfaction with the home. It was not evident how the information collected had been used, or acted upon. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 11 Ways of increasing the value of this consultation were discussed with the senior on duty. Service users activity plans detail some household tasks, such as room tidying. Staff reported that service users are often reluctant to undertake this activity. Some service users have very limited verbal communication, and it was positive to hear of work being undertaken with a Speech and Language therapist to support staff to develop the required communication techniques. The plan of care regarding communication needs to be much more explicit, and to give staff very clear guidance on how to communicate. Risk assessments had been subject to significant review and development, and were much improved from the last inspection. The documents must be signed and dated. It was not evident that the staff had returned to the risk assessments after a critical incident. This must be undertaken to ensure the control measures remain appropriate, and the risk is still well managed. Specific risks relating to service users behaviour, travelling and epilepsy were tracked, following regulation 37 notifications received since the last inspection. The documents surrounding these issues were all found to require further development. Records regarding service users were all observed to be securely stored at the time of the visit. Concern was raised with the senior regarding the practice of one staff member leaving a service users door open, when he was in a state of undress. This practice must cease. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 12 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): 11,12,13,14,15 and 17 Service users do have opportunity to undertake activities in the home and community. This isn’t with the frequency required by the men’s needs, or to ensure they have an interesting and varied lifestyle. Service users are supported to maintain contact with their family and friends. The planned menu is varied and nutritious, offering a choice at each meal. The record of food eaten does not indicate this is followed, or that the food offered meets the service users needs. EVIDENCE: The activities planned and offered to one service user were tracked. It was evident the activities actually undertaken varied significantly from the activities planned, and staff must build some form of evaluation into the activity plan to establish the cause for this. Staff reported that drivers were not always available to enable community activities to take place. Analysis of the rota identified that the best use of drivers is not always made, with some shifts having two drivers, and others none. A review of the way the rota is written, and the way activities are planned must be undertaken to ensure best use of resources is made. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 13 Staff on duty worked hard to offer a range of in house, and local activities during the time of inspection. This included tabletop games, singing, TV, and assisting with jobs in the house. The inspectors concluded the greatest work remains to be undertaken with service users who have a sensory impairment. The way in which transport for activities and meals out, are funded must be reviewed. It was of concern to note service users had paid for taxis when drivers were not on duty, and that service users had purchased meals for themselves, staff and other service users. An immediate requirement that this be explored, and service users reimbursed money spent was made. The plan of care contained a specific plan to ensure contact with the service users family was maintained. It was good to see important family dates recorded. Risk assessments and support for the service user to underpin this area were in place. The menu of food showed a varied diet is planned, and that service users have choices regarding what to eat. The record of food eaten did not evidence that such varied opportunities exist. The stock of food available was plentiful, and included good quality brand products. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 14 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 and 20 Service users are supported to undertake personal care each day to a high standard. Service users are supported to attend health care checks and monitoring. Plans of care to underpin healthcare needs are in place, some of these need to improve to ensure needs are consistently well met. Medicine management of products blister packed was good. Work to ensure service users receive the right amount of medication at the right time must be undertaken, when medicines are not blister packed. EVIDENCE: The inspectors met with all five men accommodated at the home. They had all been supported to undertake personal care, and they all looked very well presented. It was evident the men had been supported to purchase some new clothes. The men all looked very comfortable, and individual in the clothes they were wearing. The records of healthcare tracked showed that the men had been supported to undertake all routine health screening, and appointments specific to them. The plans of care regarding healthcare needs were much improved. An immediate requirement regarding epilepsy care was made. The documents inform staff to undertake actions in which they are yet to be trained, using medication, which is not currently available in the home. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 15 Interim plans until this is operational must be put in place. Other documents developed, including the seizure monitoring sheet were very detailed. Two incidents tracked caused the inspectors concern. In one incident a service user was noted to have the shakes after being administered PRN medicine, and it was not evident this was followed up, in the second incident a service user fell over and hit their head. The person went on to sleep for an hour, and staff did not seek medical attention. This is a possible sign of concussion. Inspectors left an immediate requirement that further exploration of these incidents be undertaken, and that staff receive refresher training in first aid. Most plans sampled contained some very specific information to ensure staff were aware of service users needs and how to meet them. Examples in some plans where it had been recorded, “You must support me to….” or “I need help to…” were identified. These must be further developed to provide more specific guidance. Plans of care and risk assessments regarding the level of support and checks service users need at night must be developed. At present service users are checked half hourly throughout the night, which is very frequent, if there are no specific risks, associated with their night care needs. Service users accommodated at Bevis House have some difficult to manage behaviours. One regulation 37 notification received in October 2005 informed the CSCI a physical intervention had been used. Staff must ensure the plan of care and post incident records regarding this are developed to be consistent with the Department of Health “Guidance for Restrictive Physical Interventions” document. It was evident during the inspection that some staff requires further help to undertake the observations of service users in a more discreet, yet effective way. Medication management of medicines in blister packs was good. An audit of six medicines not blister packed was undertaken, of these three were incorrect, identifying that service users had been given either more or less of the medicine than was prescribed. The acting manager must ensure that audits are undertaken, to ensure service users get the right medicine at the right time. One medicine had changed in dose recently, The MAR chart and medication label must be amended to reflect this. Two service users had protocols for as required (PRN) paracetamol. This was not written on the MAR, and stocks of the medicine were only available for one person. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 16 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 and 23 No complaints have been received. Service users are informed about how to raise their concerns. Threats to service users safety and welfare remain unacceptably high. Service users have harmed other service users that live in the home. EVIDENCE: The home has received no complaints. It was pleasing to see in service users comment cards, and in minutes of service users meetings, that service users are aware of who to complain to in the event of being unhappy with any aspect of their care and support. The CSCI has been notified of incidents that have resulted in service users or staff being harmed by other service users in the home. It was evident that the acting manager had worked hard to draw this to the attention of the right people, and to do as much as is within her power to keep people safe. The risks to service users of physical harm, or of being verbally abused remains unacceptably high. In October 2005 the CSCI was notified of ten incidents. Examples of these incidents included a member of staff being punched in the face, one service user hitting another, the person hit then retaliated by holding the service user in a strangle hold, and one service user being punched in the face twice. The acting manager has made Social Care and Health aware of these incidents and the CSCI is pursuing these incidents as Adult Protection. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 17 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 and 30 The environment at Bevis House requires attention to the furnishing, décor and cleanliness to ensure the comfort and safety of service users. EVIDENCE: No changes have been made to the décor or furnishing of the home since the last inspection. Bevis House was purpose built as a care home. It was not apparent that cyclical re-decoration and refurbishment had been undertaken since the property opened. A condition of registration was that six matters concerning the homes environment be rectified by 31/7/05. These remain outstanding. The décor throughout the home was tired and in some places damaged. Furniture in all of the communal rooms, and some bedrooms was broken, or very worn. This must be replaced. The acting manager reported that she had completed an audit of the home, and forwarded this with quotes to the provider regarding this work. The kitchen cupboards and drawer fronts were peeling in places, and a burn mark was evident on the worktop. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 18 Some cupboard and drawer fronts were loose. The kitchen must be maintained in an adequate and safe state of repair. The property did not have a homely or comfortable feel. Lounge furniture was largely placed at the edge of the room, only overhead lighting was available. This was not conducive to creating a positive or relaxed atmosphere. Flooring throughout the home was seen to require a deep clean, and if this is ineffective replacing. The flooring in one service users room was not well suited to his needs. Faecal staining was evident on the floor, where cleaning had been ineffective. This must be urgently replaced. Each service user has a single room. All have a wash hand basin. None have ensuite. The room’s contained personal items of the person accommodated, but had not been personalised to any significant degree. The home has an assisted bath, and level access floor draining shower. Communal space is provided in a large lounge, dining room, kitchen, and garden. A fridge freezer, and the broken fly screen remain at the home waiting to be discarded. This must be undertaken. Inspectors were cold throughout the time of their visit. A number of windows were open, to ventilate the home. Staff reported that the effectiveness of radiators within the home varied, and the some rooms were warmer than others. An immediate requirement that this be addressed was made. The standard of cleanliness was improved from the previous inspection. Attention is still required to ensure floors are hovered as required, and that spills on floors and surfaces are effectively cleansed. The kitchen fly screen had been removed. Environmental health officers had previously required this, and a replacement must be provided. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 19 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 and 34 The number of permanent staff is not adequate to continuously or safely meet the needs of service users. Staff require further training to ensure they have the skills to undertake their job role. Recruitment records were available for all staff. Staff had received detailed regular supervisions. Staff reported feeling supported to undertake their job role. EVIDENCE: The rota showed that the minimum number of staff (four) is provided, but that this is regularly achieved by two permanent staff and two agency staff working in the home. The rota identified that while some consistency is achieved, this is not always the case. Inspectors could not establish that the team of staff on duty always had the required skills and training to undertake the required one to one work, or to that they had been trained in challenging behaviour-including the use of Studio three techniques. The service users other specific needs, including eating and drinking, stoma care and communication needs would also prove difficult for staff unfamiliar with the home to meet. Examples of temporary staff working inconsistently with service users plans of care (due to their ignorance of peoples needs) were shared during the inspection. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 20 The inspection also identified some positive interactions. The comment cards received from service users, relatives and health professionals regarding staff were all positive. The inspectors were particularly concerned at the arrangements for covering staff breaks. Most staff work long days, which entitle them to a one-hour break. This results in the number of staff on duty being reduced to three for at least four hours each day. Staff at Bevis are currently supporting one service user accommodated out of the home. Examples of staff being called out of Bevis House to support this service user, or to administer medication were of serious concern. Three recruitment files were assessed. All files had the required documents. In two files the quality of references were not detailed, and in this instance the inspector would have expected a third reference to have been sought. Staff have received regular supervisions this year. The record of supervisions was very detailed, and staff reported feeling supported by the acting manager. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 21 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): 37,41 AND 42 The management and operation of the home has improved. Significant further work is required to ensure the outcomes for service users are safe, well planned and consistently met. EVIDENCE: An acting manager has been recruited. The CSCI are awaiting an application for registration from this candidate. It was very evident that the home has benefited from clear leadership, and that some significant strides forward have been made since the last inspection. Two comment cards received by the CSCI supported this, one stating, ”A big improvement since the new staff have taken over” and the other, “The new manager is very supportive and staff are working with me.” It is anticipated the outcomes for service users will also improve as new systems, and styles of work continue to be implemented. Records of regulation 26(Owner visits) could not be located, to evidence these had been undertaken as required. One record was available for 2005, dating back to August. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 22 The frequency of these must increase. The money and financial record of two service users were assessed. Records were robust, and receipts were available to underpin the purchases. The use of money to purchase meals and to pay for taxis must be reviewed. The Practice of service users paying for the meals of their peers and staff is unacceptable, and monies paid out must be reimbursed. The staff had undertaken testing of the fire alarm and emergency lighting as required. A fire drill had been undertaken. The fire risk assessment was due for review. West Midlands Fire service visited the home in November 2005, and identified one set of double doors required adjusting to ensure they fully close into the rebate. This work must be undertaken. The laundry room was open during the inspection. Detergent and fabric softener were unguarded, and it has been required this be risk assessed and action taken as required to protect service users from these substances. Hot water outlets are tested to ensure safe water delivery temperature. Records evidence that fridge, freezer and core food temperatures are checked a required. Records to evidence the service and insurance of the transport were available. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 23 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 X X X X X Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 1 1 2 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 1 3 2 X 2 LIFESTYLES Standard No Score 11 1 12 1 13 1 14 1 15 3 16 1 17 Standard No 31 32 33 34 35 36 Score X X 1 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bevis House Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 2 X X X 1 2 X DS0000062630.V266148.R01.S.doc Version 5.0 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulatio n 12(1a) 12(3) 16 2m-n Requirement Outstanding from the previous inspection. The plans must show evidence of consultation with the service user or their representative. Outstanding from the previous inspection. Service users plans must detail their aspirations and goals and how these are to be met. Outstanding from the previous inspection. Service users must be offered opportunity to decision make regarding their care and lifestyle. Outstanding from the previous inspection. Restrictions placed on service users must be stated in the service users plan, with the rationale for implementing them on how the impact to the individual will be minimised must be included. Evidence that information collected from service users DS0000062630.V266148.R01.S.doc Timescale for action 01/02/06 2 YA6 12(1)(a) 01/02/06 3 YA8 12(3) 16(2m-n) 09/01/06 4 YA8 12(1)(a) 12(4)(a) 01/02/06 5 YA8 12(3) 09/01/06 Bevis House Version 5.0 Page 25 6 7 YA9 YA9 13(4) and 17 13(4)(ac) 8 YA10 12(4)(a) 9 YA11YA12 16(2)(mn) during consultation is used to develop the service must be available. All risk assessments must be signed and dated. The risks associated with transport, and epilepsy must be further assessed, and current control measures included in the document. Staff must ensure they work in such a way to protect the service users dignity and privacy at all times. Outstanding from the previous inspection. Service users must be offered opportunity to undertake activities of their choice at home and in the community. The success of activities, and reasons why activities were not undertaken must be kept evaluated, and information collected used to inform service development. The allocation of drivers on the rota must be reviewed, to ensure this resource is used to service users best advantage. The use of service users money to fund meals out and taxi travel must be reviewed. Money spent inappropriately must be reimbrued. The record of food eaten must be reviewed to ensure a varied and nutritious diet is offered. Records on the use of physical intervention require improvement to ensure they meet the Department of Health guidance for restrictive physical interventions (2002). Plans of care and risk assessments must be developed regarding service users nighttime DS0000062630.V266148.R01.S.doc 09/01/06 29/11/05 01/12/05 01/12/05 10 YA12 12(3) 16 2m-n 24 a-b 01/02/06 11 YA13 18(1)(a) 01/12/05 12 YA13YA17 13(6) 01/12/05 13 14 YA17 YA19 16(2)(i) 12(1)(a) and 13(7-8) 01/02/06 01/12/05 15 YA9YA19 12(1a) 12(4a) 13(4c) 01/12/05 Bevis House Version 5.0 Page 26 16 17 YA19 YA19 12(1)(a) 18(1)(a) 12(1)(a) and 15 12(1)(a) 13(4)(c) 18 YA19 needs. Night checks must be undertaken proportionally to the level of risk and needs identified. Staff must receive refresher 01/02/06 training in emergency first aid. Plans of care must clearly detail 01/02/06 how service users needs are to be met, and make explicit the support staff are required to give. Outstanding from the previous 09/01/06 inspection. Incidents must be reviewed and evaluated to inform and direct care practice. Outstanding from the previous inspection. Guidance on how to communicate with service users must be provided. Outstanding from the previous inspection. Stock checks for non blister packed medicines must be undertaken. Amendments must be made to the Medication Administration record and medicine packet if the prescribed dose changes Prescribed medicines must be available for administration. 19 YA8YA19 12(1)(a) 12(4)(b) 09/01/06 20 YA20 13(2) 19/12/05 21 YA20 13(2) 19/12/05 22 23 24 YA20 YA24 YA24 13(2) 23(2)(p) 23(2)(d) 19/12/05 The temperature of the home 22/11/05 must be maintained close to 21°c Outstanding from the previous 01/02/06 inspection. The hallway, lounge and dining room must be redecorated. Furniture and fittings must be provided in these areas, and maintained to a good standard of repair. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 27 25 YA24 13(3) and 23(5) Outstanding from the previous inspection. The kitchen must be maintained in a safe and hygienic state of repair. Outstanding from the previous inspection. The floor in 4 service users bedrooms must be cleaned to a satisfactory standard. The floor in CP and PS room must be replaced. Bedroom furniture must be replaced for all service users. Outstanding from the previous inspection. A satisfactory level of cleanliness must be maintained in all areas of the home. Outstanding from the previous inspection. A fly screen must be refitted to the kitchen window. Outstanding from the previous inspection. All staff vacancies must be recruited to. Efforts to maintain consistency in the staff team must be applied. Outstanding from the previous inspection. The number of staff provided must be reviewed to ensure it is adequate to meet service users needs. Staffing must be reviewed after the completion of care documents and risk assessments to ensure the compliment is adequate to 01/02/06 26 YA27 16(2)(c) 01/02/06 27 YA30 13(3) and 23(5) 01/12/05 28 YA30 13(3) and 23(5) 18(1)(a) 09/01/06 29 YA33 05/12/05 05/12/05 30 YA33 18(1)(a) Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 28 meet service users needs. 31 YA35 18(1)(c) Outstanding from the previous inspection. All mandatory and service user specific training and updates must be provided to all staff employed in the home. Outstanding from the previous inspection. 01/03/06 32 YA37 8(1)(a-c) 30/09/05 33 YA41 34 YA42 35. 36 YA42 YA42 37 YA24YA37 An application for registration of the acting manager with the CSCI must be received. 26 Outstanding from the previous inspection. Regulation 26 visits must be undertaken monthly, and a record of such maintained in the home. 13(4)(c) Outstanding from the previous inspection. Hazard data sheets must be available for all COSHH products used in the home. 23(4) The fire risk assessment must be updated and kept under review 13(4)(c) Risks associated with the laundry must be assessed and action taken to protect service users from harm. CSA 2000 Action must be taken by the Section providers to meet, or to apply to 24 vary the conditions of registration to avoid enforcement action being considered or taken. 09/01/06 01/02/06 09/01/06 25/11/05 23/12/05 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 YA14 Good Practice Recommendations It is recommended that the purpose of activities be DS0000062630.V266148.R01.S.doc Version 5.0 Page 29 Bevis House 2 3 4 5 YA19 YA20 YA30 YA34 explored, and made clear. It is recommended that staff receive further support and guidance regarding the observation of service users. It is recommended that arrangements for the provision of paracetamol or cold remedies be made for all service users. It is recommended that a cleaning schedule be developed and implemented. It is recommended a third reference be obtained when references only state the length of employment or are from friends or colleagues. Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI Bevis House DS0000062630.V266148.R01.S.doc Version 5.0 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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