Inspection on 09/04/08 for Coalway House

This inspection was carried out on 9th April 2008.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coalway House 03/03/09

Coalway House 03/10/07

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Coalway House Coalway House 54-56 Coalway Road Penn Wolverhampton West Midlands WV3 7LZ Lead Inspector Debra Lewis Key Unannounced Inspection 9th April 2008 11:00 Coalway House DS0000068648.V363557.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 Coalway House DS0000068648.V363557.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. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coalway House Address 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) Coalway House 54-56 Coalway Road Penn Wolverhampton West Midlands WV3 7LZ 01902 341204 Swan Village Care Services Limited Care Home 9 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (9) of places Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide personal care (excluding nursing) and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 9 Mental Disorder (MD) 9 The maximum number of service users to be accommodated is 9. 2. Date of last inspection 3rd October 2007 Brief Description of the Service: Coalway House is a care home providing personal care for up to 9 adults, male or female, with a learning disability and/or mental health needs. The home has 9 single bedrooms that are on the ground and first floors. All bedrooms meet minimum space requirements and have en-suite toilets and hand basins. Four rooms also provide en suite shower facilities. There are also communal W.C.s and a separate bathroom on each floor, communal lounges on each floor, a kitchenette on the first floor and a ground floor kitchen and dining room. There is also a small laundry room and a large rear garden with a patio area. The home has its own transport and is well served by a regular public transport system. It is close to local shops and facilities, and is about a mile from Wolverhampton City Centre. The registered provider of the home is Swan Village Care Services Limited, a wholly owned subsidiary of Minster Pathways Limited. The nominated responsible individual is Mr Colin Farebrother. At the time of registration in April 2007 there was a manager in post who was registered to manage the home. However, he left the home before anyone moved in and the home has since had three acting managers. The most recent, Eunice Harrison, has been in post as acting manager since November 2007. Details about the home’s fees and facilities are available in a service users’ guide, which is due to be updated. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Inspection. This means that we, the Commission, checked all of the standards that have most impact on service users. It was an unannounced inspection, which means that staff and managers did not know the inspectors were coming to the home. This report includes findings from the visit to the home, as well as any relevant information that has been received about the home since the last inspection. We were in the home from 11 a.m. until 5.15pm. We met and talked with 3 of the 8 service users; with several staff on duty; and with the acting manager. This report also includes some findings from two previous, shorter inspections of the home, which we did in January and February 2008 because we wanted to make sure things were improving in the home. Full reports of these two inspections are available on request. What the service does well: People living in the home say they are comfortable there. They like the food and choose what they want to eat. They get on well together. They see their families if they want, and staff help with this. They are getting out and about more than they used to. Staff keep a record of people’s health care so they know what to do to help people living in the home stay healthy. People living in the home like the staff, and feel they can talk to staff if they have a problem. The home is clean, tidy and well kept. People can have their rooms how they like them. Staff will change the home to suit different people’s needs, for example they put in a handrail on the stairs. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: They need to make sure they always know what support people need before they move into the home, and people get up to date information about the home. They need to make sure they always have written down what care people need, so all staff can see what they need to do. They should encourage and help people to go out more, and help them with their hobbies, so they have more interesting lives. They should make people’s care plans more detailed, and more based on individual people’s different needs and wishes. This would help make sure support is given to people in the way they want and need. All details about medicines should be written down to make sure it is always given safely. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 7 They should make sure staff know what to do if they were worried about someone in the home being harmed, so they could best help that person. Staff need more training to make sure they know how best to provide the support people need. They should have regular meetings with the manager to talk about how to do the work well. The home needs a way of regularly checking what it does, to make sure it keeps getting better for people who live there. They should make sure safety checks and training are always done and are up to date. This will help keep the home safe for people who live there. The home needs a permanent manager to make sure the home keeps on getting better for people living there. 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. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 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 Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People moving to the home can get information about it in an accessible format, and can visit the home before they move in. The home makes efforts to be aware of their needs before they move in, but don’t always have these needs recorded, which could cause a problem for staff whilst they are getting to know people. EVIDENCE: The home’s Service Users’ Guide and Statement of Purpose were out of date and the acting manager was about to update them, as new staff had just joined the team. The statement of purpose also needed to be updated to clarify the range of needs that the home can cater for. The service users’ guide was in an accessible format. There had been 4 new admissions since the last inspection, all transferred from another home at Sedgely Road in the previous week. Ms Harrison, the acting manager, was the registered manager of the home at Sedgely Road so knew all of the new service users well. The staff team from Sedgely Road also Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 10 moved to Coalway House with the service users so were very familiar with them and their needs. These people’s needs were different from some of the people already living in the home. There were no written assessments of their needs, but the acting manager said all the social workers were happy with the move, as they know her and the staff from Sedgely Road. She said none of the social workers did an assessment – she will do this. She said at least one Sedgely Rd staff member is always on duty and they can make sure other staff know what care is needed. This was evidenced from the rota. It was difficult to assess whether the home can meet the needs of the people who live there. There were no written assessments of the new people’s needs, but we were told their needs were mainly associated with a learning disability. Staff in the home still were not trained in mental health so were not best suited to working with people with mental health needs. The acting manager said the new service users had visited the home before moving in. One social worker had visited the home. Some had had IMCAs (Independent Mental Capacity Advocates) involved to help determine whether the move was in their best interests. Staff said the new people were settling in well and there were no problems with any other people already living in the home; there was a bit of a tendency to keep to “old” and “new” groups, but this would be expected anyway. During the inspection there was no apparent separation between the two groups of people and those we talked to said they were happy with the other people in the home. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home usually records the care needs of people living at the home, and any possible risks to them, so staff know what care to give. Sometimes they rely on staff knowledge instead of keeping a written record, which increases the risk of inadequate care being given to people living in the home. People living in the home make some contribution to decisions such as meals and activities. EVIDENCE: Previous inspections had found care plans were not in place or did not have enough details. This had caused us to have serious concerns about whether staff were aware of the care everyone needed, and whether people were getting the care they needed. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 12 On this occasion, plans seen were up to date and did contain a reasonable amount of information, with nothing obviously omitted. This should help ensure all staff know what care people need at all times. The care plans for the new people were still at their old home, but were due to be delivered that week. The care staff from the old home were working at Coalway House and there was always at least one of them on duty to work with the new people. Risk assessments had also been missing or insufficient on previous inspections. In February 2008 we issued a legal notice warning of possible prosecution if this was not put right. Risk assessments had been put in place the next time we visited the home. On this occasion they were also in place and were up to date, with no obvious omissions. This should help people living in the home to be able to do ordinary activities, with staff aware of and removing any unnecessary risks. As with care plans, the risk assessments for new people had not yet come from their old home but were due to arrive. One person living in the home confirmed that they have house meetings, to talk about things like what they’d like to eat, what activities they want to do, and where to go for trips out in the car. This helped people living in the home to feel involved in everyday choices and decisions. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 this service. People living in the home take part in some ordinary activities and community life. Some people are a lot more active than others. There are now enough staff to start to help the people who are less active with their interests. Staff support people living in the home with family contacts. People living in the home choose and like the food, and meals are healthy and varied. EVIDENCE: At the moment none of the people living in the home attend work or college. Such activities may not be appropriate for some people living in the home. The acting manager said they would be investigating college as a possibility for at least one of the new people. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 14 Records of activities showed that they varied mainly with the motivation and interests of different people. Previously there had not been many staff on duty so activities had been more difficult, but now there were usually 3 care staff available so activities were more easily available. Records for one person showed activities outside the home such as car trips and hairdresser 3 times in a week; more everyday activities such as going to the shop, watching a film, chatting with staff, playing with their cat took place about twice a day. This person was leading a fairly ordinary life. Another person’s records showed less activity, but several entries detailing offers of activities that were refused. Now the home has more staff they will be able to gather more information on people’s interests and encourage more activities and hobbies. Records showed that contact with families was supported and people living in the home talked of family visits, and of phone calls to relatives and friends. Staff said they worked on developing ordinary skills e.g. making drinks, changing bed linen, going to the shop; for some people living in the home these things had not been possible or encouraged in a previous home. Now staff worked alongside people, supporting them rather than doing “for” them. One person said she was happy in the home, and the only thing she missed was the old pub she used to go to. Routines in the home appeared to be flexible and varied. Some people living in the home had keys to their bedrooms. Some talked about going out to shops etc. when they wanted. We saw a menu, with a choice of 2 breakfasts (including cooked, croissants etc), 2 lunches and 2 teas, with a supper such as crumpets or toast. It included suggestions for people with diabetes. We saw a meal being prepared. Food looked healthy and of good quality. We advised the acting manager to get a list of proscribed foods for diabetics and put it up in kitchen for easy reference by staff. Staff said they were trying new meals e.g. stir fries, which the new people preferred. People living in the home said they liked the food and could choose what they wanted, though one said they did not see a menu. They said it was fresh food. One new person said there were not enough takeaways. Staff are trying to establish a mix of healthy meals to suit everyone’s preferences. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home usually records what care people need for their health and for personal support, so staff know what to do. Plans are not developed in a person-centred way, so focus on individuals could be improved. Medication is mostly managed safely. Some improvement is still needed to make it safer for people living in the home. EVIDENCE: In October 2007 we had serious concerns about the home’s ability to meet people’s personal and healthcare needs. These concerns had also been raised by health and social care professionals involved with people living in the home. We also had concerns about the way medication was handled in the home. In both areas we had started to see improvements by February 2008. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 16 On this occasion, the healthcare records, and health and personal care plans that we checked were in place and up to date. We saw plans for people’s specific health needs, such as diabetes, weight loss and mental health, which were up to date and had had basic details needed. Records were also being kept of health checks such as weight and blood sugar levels, in accordance with the care plans. This meant people living in the home were getting the care that was planned for them and their health and personal needs were being taken care of. Plans could be revised to be more person-centred. This would help improve the focus on individual’s personal needs. A pharmacist inspector inspected the control and management of medication within the service on this occasion and found the following: The service had recently obtained and installed new medication storage cabinets, which were locked and secure in a locked office. We saw that medication was stored in a neat and organised manner, which enabled people’s medication to be easily located. The person in charge held the medication keys, which means that there was restricted access to the medication cabinets, which increased the protection and safety of people’s medication. There was no safe secure storage available for storing medication that requires refrigeration, however a refrigerator was on order from the supplying pharmacy. Some medication, which requires special lockable storage arrangements, was correctly stored in a cabinet that met the required legal specifications. This means that medication was stored correctly according to legislation. The manager informed us that only trained and competent members of staff administered medication. We saw some medication training certificates for staff who were administering medication. This means that people who live in the service were being given medication by staff who had received appropriate training. We looked at the medication records, which documented a staff signature to show that medication had been administered or a code had been recorded to explain why medication had not been administered. There was one example of a medicine record where a code was documented that did not give a reason why the prescribed medication was not administered. We saw that a code ‘x’ had been documented onto the medicine record from 24/3/08 to 31/3/08. We asked the manager why the medication had not been administered for 8 days, who explained that the General Practitioner (GP) had not written or supplied the prescription for the medication. A new prescription was provided and the Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 17 medication was administered from 1/4/08. We checked the daily notes for the person, however there was no information documented about this error. This means that the individual persons healthcare records were not kept up to date with important and relevant medication information. We saw no documented evidence to show whether the service was undertaking any checks on the medication records and the medication administered to the residents. We undertook a check on one person’s medication and we were able to check that the medication provided in a prepacked blister pack from the pharmacy, was correct. However, for any medication supplied in the original manufacturers container a full check could not be undertaken. For example, the dates of opening of medication were not recorded and any balances of medication were not recorded and carried forward onto a new medicine record chart. This means that it was not always possible to check if medication had been given as prescribed by a medical practitioner. We saw records for the receipt of medication from the pharmacy, which meant that the service ensured that levels of medication were kept at a safe level. Some people were prescribed medication to be given when required. For example, one person was prescribed a medicine to calm and control their behaviour when required. The medicine records showed that staff had not administered the medication recently. We saw a form headed ‘Coalway House PRN Protocol’ (PRN is a Latin abbreviation which means ‘when required’). This was located next to the person’s medication record. The form stated ‘When is medication required – Aggression’. It did not record any further information to help inform staff under what specific circumstances this medicine should be administered. This means that due to a lack of detailed records it was not possible to know when to administer the medication correctly. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home feel they can tell staff if they have a concern. Staff could be more proactive about this. Staff mostly know how to respond in case of suspected abuse of people living in the home, but the home’s policy is misleading and could prevent a proper investigation if staff were to follow this. EVIDENCE: No complaints had been made about the home to the Commission. The home had a suitable complaints policy, but the contact details for the Commission were out of date. There was a record book for complaints, with none recorded. We advised it is good practice to record even minor concerns, to ensure people feel they are taken seriously and so the home can show what action is taken in response to all concerns raised by people living in the home. 3 people living in the home said they would talk to staff, or to the acting manager, if they had a problem. The home’s Adult protection Policy was misleading as it stated “..all reports of abuse, no matter how minor, should immediately be investigated and acted upon by the person in charge. Staff should use tact and sensitivity in talking to Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 19 the suspected victim.” In fact NO investigation should take place unless directed by the local authority Safeguarding coordinator, and staff should not be questioning any possible victim of abuse. There was also no contact number for the police or for the Safeguarding coordinator. We saw training records that showed that most staff had had training in abuse awareness, or were booked onto a training course. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained and comfortable for the people who live there. EVIDENCE: We toured most of the home, including seeing a few bedrooms. The home was clean, tidy and generally in good order. Weekly environmental checks e.g. on sockets, plugs, lighting, doors, flooring and garden, were being done. The home was being kept in a safe and pleasant condition for the people living there. It could do with being made a little more homely in the shared areas; this had been delayed until it was known whether the people living in the home were staying permanently, as it needed to be done according to their tastes. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 21 Bedrooms seen were furnished to the taste of the person who the room belonged to. All bedrooms had an ensuite toilet and hand basin. Some also had a shower. There were also shared bathrooms on both floors. The soap dispenser in the downstairs bathroom was mouldy and the acting manager agreed to replace it immediately. Upstairs the new lounge was in use, mainly but not exclusively by the new people living in the home, and one bathroom was being converted to kitchenette for their use. This would enable people to make drinks and snacks without having to carry them up and down stairs. We discussed people having to go through the smoking room to get to the garden. The acting manager said they could consider putting outside door from dining room. One new service user had a slight difficulty with stairs; a handrail had been fitted to make it easier for her. During the inspection she was seen up and downstairs. The home was clean and tidy during the inspection. The kitchen was clean. Temperature checks were done on fridges and freezers. Laundry was not carried near or through the kitchen. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home mostly have training. If they don’t, it is now being arranged. This will help improve the care given to people living in the home. The home now does proper checks on staff before they start work in the home, to help prevent unsuitable people from working with residents. Staff need some more training, and they are not being supervised regularly. This means they are not working as effectively with people living in the home as they could be. EVIDENCE: We have had concerns about staffing in the home, particularly about the right checks not being done on staff before they started work in the home, and about staff not having the training they need for the work. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 23 The situation had improved on this inspection, partly because of the staff from Sedgely Road moving to Coalway House. The acting manager had also been getting staff records established. Of the new staff team, 9 had NVQ (National Vocational Qualification) level 2, 1 was doing it and 3 others had not got it. This met the National Minimum Standard for 50 of staff to have this qualification. This should benefit people living in the home by having staff with a qualification in care. Service users said they liked staff. One said they were her friends. Another said he liked them but was a bit shy of the new staff as they were “strangers”. This is an understandable response to new groups of people. One service user said staff were polite here, better than where she had moved from. Staff levels had improved since the last inspection. This was because of the staff joining the home from the other home at Sedgely Road, which had boosted the numbers of staff. The rota showed the acting manager plus 3 care staff on duty during the day, enough to meet the care and social needs of people living in the home. We checked staff recruitment records for 5 staff members, 4 of whom were employed before the acting manager began work in the home. The acting manager had been working on completing their records but was still waiting for some information. All had application forms. Most had a full work history, but it was missing for one staff member and undated for another. All had a CRB (Criminal Record Bureau) disclosure, but start dates for 2 were missing, meaning we could not check if their CRBs had been obtained before they started work. The acting manager agreed to establish start dates and to gather accurate work histories, where this had not already been done. No agency or staff from other homes were working at Coalway House. We stressed that if they do, the acting manager must ensure all their records of in the home. This had not been done in the past. Staff training still needed attention, but the overall situation had been improved by the addition of the staff team from Sedgely Road. Also the acting manager had been booking training for staff. Staff were due to do a 1-day mental health course at Beckminster House ( a local social services venue) as a very basic introduction, then the acting manager said she would be looking for further training in mental health for staff. This would improve their understanding of people with mental health needs. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 24 Staff mostly had basic training, or were booked onto courses. The acting manager needs to ensure all necessary training takes place so staff can give the best quality of care to people living in the home. Supervision records were not complete. A regular system was not yet established. This should be done to ensure the acting manager can effectively oversee the care given to people living in the home . Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 25 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, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s manager is experienced and the people living in the home like her. She has made improvements since being in post at the home. She has not applied to be registered with the Commission for Social Care Inspection. The home does not yet have a system for regularly checking and improving the service they provide to people living in the home. The home is mostly kept safe for people who live there, but some more work is needed to make sure it is always as safe as possible. EVIDENCE: Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 26 The home has had 4 managers since registration. The current acting manager has been working there since November 2007. It is intended that she will apply for registration as manager of the home. She is about to complete her Registered Manager’s Award and is enrolled on a mental health course. Staff said she was supportive and “Always there for us 100 ”. People living in the home liked her. She had been working hard to make improvements to the way the home is run. There was no established quality assurance system. The acting manager said she will set up a system as she had at Sedgely Road, using monthly audits and random checks, surveys of people living in the home, relatives, professionals and staff. It will be done in the home, not by the company, and will incorporate Commission for Social Care Inspection reports and reports made by the registered provider. It will include an action plan and improvements needed. We saw risk assessments for all significant areas, except gas, electricity and window restrictors. Regular safety checks were being done on gas and electrical equipment and all windows checked were restricted. Risk assessments were due for updating as they had mostly been done in 2007. The risk assessment for fire was not signed or dated. We advised this should be done. Fire checks were mostly being done although some records could not be found, despite other evidence checks had been done. Staff fire safety training had been done in January 2008. It needs to be done regularly from now on. There was no evidence of fire drills and we advised the acting manager to prioritise this urgently. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 2 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 1 X X 2 X Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 28 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 YA20 Regulation 13(2) Requirement Care plans should document up to date medication records. This is in order to ensure that medication records for people who use the service are accurate and ensure they are protected from harm. (Repeated from Key Inspection 3.10.07) 2 YA20 13 (2) Medicine records for the administration of medication must document what has been administered or record a reason why it was not administered in order to ensure that the people who use the service are safeguarded. There must be an appropriate policy on Safeguarding Adults. This is to ensure that staff know what to do if they thought someone in the home was being harmed. (Partially repeated from Key Inspection 3.10.07) 30/05/08 Timescale for action 30/05/08 3 YA23 13(6) 30/05/08 Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 29 4 YA42 23 (4A) Fire drills must be carried out at the frequency advised by the local fire authority. This is to ensure that staff and people living in the home know what to do in case of fire. 30/05/08 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 The registered provider should ensure the accuracy of the statement of purpose. (Repeated from October 2007) 2 YA2 A system should be put in place to ensure that in future no-one is admitted to the home before the home has a full assessment of their needs by a person competent to do so. A system should be put in place to ensure that in future care plans are put in place in the home immediately someone is admitted to the home. Care plans should be developed in a person-centred way. A system should be put in place to ensure that in future risk assessments are put in place in the home immediately someone is admitted to the home. Now the home has more staff, they should thoroughly assess everyone living in the home with regard to occupational, community and social interests, and develop plans to improve this area of life for the people living in the home. Consideration should be given to provision of keys to people living in the home. If it is not considered desirable, the reasons should be recorded. It is recommended that there is a documented protocol DS0000068648.V363557.R01.S.doc Version 5.2 Page 30 3 YA6 4 5 YA6 YA9 6 YA12 YA13 YA14 7 YA16 8 YA20 Coalway House available which describes the care to be given to residents who could become agitated or aggressive. This must include details for the administration of medication prescribed ‘when required’ for behaviour management. 9 YA20 A system should be introduced to ensure that accurate medicine audits can be done and check that people who use the service have been administered medication according to the directions of a General Practitioner. The acting manager should encourage staff to record all concerns raised by people living in the home, however minor. This will help to ensure that all concerns are treated seriously and acted upon and will help the acting manager to monitor any areas needing attention. The registered provider should consider the best way to prevent staff and people living in the home from being affected by smoke when passing through the smoking room in and out of the garden. The registered provider and the acting manager should establish a system to ensure that in future no staff work in the home until the home has all legally required records in place to show they have been properly vetted. This is to help protect people living in the home from unsuitable staff. The acting manager should ensure that she completes the process of making sure full staff records are in place for all staff working in the home, without delay. Records should include training and recruitment, including all aspects described in schedule 4 of the Care Homes Regulations. This is to help protect people living in the home from unsuitable staff. The acting manager should ensure all necessary staff training is now booked and completed without delay. The acting manager should establish a regular system of staff supervision without delay. The registered provider should ensure that stable management is established in the home, and that an application for a suitable person to be registered as manager of the home is made to the Commission without further delay. DS0000068648.V363557.R01.S.doc Version 5.2 Page 31 10 YA22 11 YA28 12 YA34 13 YA34 14 15 16 YA35 YA36 YA37 Coalway House 17 YA42 All records of risk assessments and health and safety checks should be easily available and up to date. Coalway House DS0000068648.V363557.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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