Inspection on 29/05/07 for Conway House

This inspection was carried out on 29th May 2007.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Conway House 29/05/08

Conway House 29/11/05

Conway House 09/06/05

Conway House 12/01/05

Conway House 11/08/04

Conway House 13/03/04

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 Conway House 44 George Road Oldbury West Midlands B68 9LH Lead Inspector Lesley Webb Key Unannounced Inspection 29th May 2007 09:45 Conway House DS0000004821.V330235.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 Conway House DS0000004821.V330235.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. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Conway House Address 44 George Road Oldbury West Midlands B68 9LH 0121 552 1882 F/P0121 552 1882 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) Mrs Julie Birks Mr Peter Birks Mrs Lynne Ann Strudley Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1), Physical disability (7), of places Physical disability over 65 years of age (1) Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 1 PD(E) and 1LD(E) and up to 7 LD/PD Date of last inspection 29th November 2005 Brief Description of the Service: Conway House is a large bungalow, which was originally built in 1954. It was converted and extended in 1994 to provide residential care for eight service users with learning and physical disabilities. The Home is situated on a suburban road, opposite a small row of shops and nearby public house. Access to the front of the Home is via a small parking area and a concrete ramp. There is a large garden to the side of the property and a sensory room situated to the rear of the house. There are eight single bedrooms, some of which have sliding doors, which lead onto the patio and give a pleasant view of the garden. The decoration and personal belongings reflect the individuality of the residents. There is a lounge area, dining room and kitchen with a separate laundry. There are two large bathrooms with toilets. One bathroom has a bath with a Jacuzzi. There is an in-house day care provision for some service users. The Home provides a range of activities for service users. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this visit over two days with the home being given no prior notice. During the visit time was spent talking to staff and examining records before giving feedback about the inspection to the registered manager and proprietor. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking three individuals care provided at the home. For example the people chosen consist of both male and female and have differing communication and care needs. The home is registered to provide long term care for people by the reason of learning and physical disability. Discussions with people living at the home were not appropriate. Therefore observation of behaviours and care practices was undertaken using a tool called the ‘Short Observational Framework for Inspection’ in order to help form judgements on care provision. This tool consists of sitting for two hours observing residents states of well being and staff interactions. No residents surveys were completed and returned to the Commission for Social Care Inspection (CSCI). The proprietor explained that no one living at the home is able to understand the questions contained within this document. Three relatives surveys were completed and returned to CSCI prior to the inspection. Information from these and from documentation supplied by the home prior to the inspection was also used when forming judgements on standards of service provided. Fees charged for people y living at the home ranges from £821.00 upwards. Additional charges are made for toiletries, hairdressing and some activities. The inspector was shown full assistance during the visit and would like to thank everyone for making her welcome. What the service does well: The homes assessment documentation covers all subjects as listed in Standard 2.1 of the National Minimum Standards for Younger Adults and policies are in place for introductory visits and overnight stays, ensuring that individuals aspirations and needs can be met. People who live at this home are assisted to participate in a range of leisure and social activities, which are supportive in helping them lead stimulating and meaningful lives. During the visit the inspector witnessed some of the people who live at the home participating in gardening and cookery. All those who joined in these activities appeared to take enjoyment from them. Staff fully support residents to keep links with their families thereby ensuring important relationships are maintained. All three relatives questionnaires Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 6 returned to CSCI state the home helps their relative to keep in touch, with one person also stating ‘I visit and am always made welcome’. The principles of respect, dignity and privacy are put into practice. For example staff were seen escorting individuals to their bedrooms in order that personal care could be given and their dignity not compromised. Staff have a good understanding of supporting people to raise concerns. As one person explained, “ I would go and talk, sit at their level, try and calm down, because they don’t communicate verbally you have to try and think what they going through”. All three relatives questionnaires received by CSCI prior to the inspection states that they have been informed of how to make a complaint about the care provided by the home if they need to and that the home responds appropriately if concerns are raised. All bedrooms are decorated and furnished to a high standard and individualised with personal possessions, photographs and stereo equipment. It is pleasing to see that colour schemes, décor and furnishings reflect resident’s individual tastes. People who live at this home are protected from harm by its recruitment procedures. Staff receive regular, formal supervision in order that they can perform their duties and support people living at the home. In addition to this regular staff meetings take place, again as aids to supporting staff to fulfil their roles. What has improved since the last inspection? What they could do better: Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 7 Further work is required to ensure care planning processes are clear and consistent, providing staff with the necessary directions of actions required to meet the behavioural and communication needs of individuals living at the home. Attempts are made to involve individuals in decisions about their lives. Further improvements will give people greater control over how their care is delivered. Residents were indirectly observed during a number of mealtimes. At times when all residents are at home and participating in a meal together evidence indicates that some individuals find this difficult resulting in incidents of behaviour. The inspector strongly recommends that the home reviews the current system of everyone having to eat together and waiting for others to finish eating before being able to leave the area in order that person centred approaches to care and support are promoted. Some further improvements to medication are required to ensure systems safeguard those living at the home. Improvements to some protection policies, practices and procedures are required to ensure people are not at risk from harm and their rights are protected. Further provision of some specialist training will provide staff with the necessary skills and knowledge to meet the needs of some individuals. Improvements to quality monitoring systems should take place to ensure people living at the home can be confident it is achieving its aims and objectives and that people are assured their views and opinions are not only listened to but also acted upon. 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. Conway House DS0000004821.V330235.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 Conway House DS0000004821.V330235.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a comprehensive tool so that new residents are admitted only on the basis of a full assessment thereby ensuring that their individual aspirations and needs can be met. EVIDENCE: There have been no new admissions to the home in the last 12 months, however the registered manager states that if this should occur comprehensive assessments would be completed for all perspective residents and that admission procedures would be in line with good practice and minimum standards. The files of three people who live at the home were sampled, with all containing needs assessments either completed by the relevant placing authorities or the home. The homes own assessment covers all subjects as listed in Standard 2.1 of the National Minimum Standards for Younger Adults and policies are in place for introductory visits and overnight stays. Three relatives completed questionnaires prior to the inspection and returned them to the Commission for Social Care Inspection (CSCI). Of these two state the home ‘always’ meets the needs of their relative and one ‘usually’. Evidence gathered during the inspection indicates that in the main the home meets the needs of individuals, but that further work is required specifically relating to support for the management of behaviour and communication (see sections relating to care planning, protection and training in this report). Conway House DS0000004821.V330235.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work is required to ensure care planning processes are clear and consistent, providing staff with the necessary directions of actions required to meet the behavioural and communication needs of individuals living at the home. Attempts are made to involve individuals in decisions about their lives. Further improvements will give people greater control over how their care is delivered. EVIDENCE: As at the previous inspection all of the three residents files sampled contained individual plans of care. These include detailed plans that include aims and goals for personal hygiene, housekeeping, family and relationships, socialising, recreation, mobility, eating, self-medicating and healthcare. Some of the people who live at this home have specific behaviour/communication guidelines that have been produced by specialists but these have not been included or referenced to within the homes care plans. It was also noted that a care plan has not been introduced for a named person who has recently been diagnosed with diabetes. Care plans must be introduced for any identified need in order that people living at the home are not placed at risk of Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 11 not having all their needs met. When assessing the homes practices in relation to behaviour management the inspector was concerned to find that behaviour charts (ABC’s) are not being completed for all incidents (as detailed in daily records) as per guidelines. Without full and accurate records in this area the home cannot be confident that its practices and support are appropriate for individuals concerned. Despite these omissions in records all of the three relatives questionnaires returned to the Commission for Social Care Inspection (CSCI) state the home ‘always’ or ‘usually’ gives the support and care to their relative that is expected and agreed. Observation of care practices, discussions with staff and viewing of documentation demonstrate that attempts are made to involve individuals when making decisions about their lives but that further work should take place in this area. For example documentation is still not available in alternative formats such as person centred plans. This will enable residents to participate in how their care is delivered and make their wishes and aspirations known. The proprietor explained that attempts are being made to introduce this form of care planning but that the home is waiting for involvement from outside agencies. She also explained that the home was currently gathering photographs and completing ‘life stories’ with the families of individuals. When interviewing staff the inspector asked how they communicate with people who may have limited verbal communication to find out their views and opinions. All staff demonstrated some knowledge in this area but further improvements are required. For example one person explained, “show two choices at meals, one person very much knows what he wants and doesn’t want, others only eyes and facial expressions. The longer you work here the more you pick up” and another “When I first started it was difficult but after working here a while you get to know them, one will hold self in a certain way and we know that means they need the toilet, one will walk in kitchen and we know they either want a cup of tea or something to eat”. When discussing the findings of the inspection with the proprietor and registered manager the inspector instructed that further guidance be given to staff in this area as none of those spoken to made reference to communication aids as detailed in care plans and guidelines issued by outside specialists and some staff did not know how to operate a mechanical communication aid in place for a named person. Improvements in this area will ensure staff can be confident of communicating with individuals based on their needs and capabilities. As with care plans comprehensive risk assessments were found to be in place for most areas of need including walking with frames, personal care, meals, epilepsy and bathing with only minor work needed in this area. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at this home are assisted to participate in a range of leisure and social activities, which are supportive in helping them lead stimulating and meaningful lives. Staff fully support residents to keep links with their families thereby ensuring important relationships are maintained. Generally daily routines are operated on the principles of choice and respect. EVIDENCE: Observations made during the visit indicate that although attempts are made to ensure resident’s routines are flexible some improvements could be made in this area (see meals section of this report). Some individuals were seen moving around the home freely, choosing where to sit and who to interact. Information supplied by the home prior to the inspection states that in-house activities include art and craft, sensory, massage, cooking, gardening and shopping. External activities include church, bowling, cinema, theatre, pubs, restaurants, sensory facilities and picnics. During the visit the inspector witnessed some of the people who live at the home participating in gardening Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 13 and cookery. All those who joined in these activities appeared to take enjoyment from them. All of the people who live at this home have differing communication needs that resulted in the inspector being unable to ascertain their views on activities. Therefore records were examined in order that the inspector could be satisfied that the home is meeting its obligations in this area. A diary has been introduced since the last inspection for recording activities. Upon examination of this the inspector found that very little information is recorded. For example it states the activity such as art and craft but not who participated or any evaluation of the activity. Praise was made by relatives of individuals living at the home on the three questionnaires returned to CSCI regarding activities. For example one person states as one of the best things the home offers is, ‘Taking them out lots of times a week to cinemas, lunches out, shopping and church on Sunday, lots of other things too’ and another ‘Clients taken out often and engaged in activities in the home’. Staff continue to strive hard to include families in important aspects of residents lives and build positive relationships. All three relatives questionnaires returned to CSCI state the home helps their relative to keep in touch, with one person also stating ‘I visit and am always made welcome’. Menus supplied by the home prior to the inspection indicate that residents are not offered a choice of a main meal each day. This was investigated during the inspection with the proprietor stating that due to changes in dietary and nutritional needs the home has ceased offering choices in order that specific needs can be managed. The inspector explained that the home must ensure that its practices do not impinge on the rights of other individuals who do not have specific needs in this area and that the current system must be closely monitored. All residents’ files that were sampled contained nutritional risk assessments and monthly weight records, but none contained sufficient evidence to support the current practice of restricting choice at meal times for everyone living at the home. Residents were indirectly observed during a number of mealtimes. All residents at home at mealtimes were seen sitting in the dinning room, with many requiring assistance from staff. At times when all residents are at home and participating in a meal together evidence indicates that some individuals find this difficult resulting in incidents of behaviour. The dining arrangements were discussed with the proprietor who states that different alternatives have been tried but none successful due to some residents requiring one to one staffing at mealtimes. The inspector strongly recommends that the home reviews the current system of everyone having to eat together and waiting for others to finish eating before being able to leave the area in order that person centred approaches to care and support are promoted. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Observations and examination of records confirm that resident’s privacy and dignity is respected. For example staff were seen escorting individuals to their bedrooms in order that personal care could be given in order not to compromise their dignity and assessments and care plans contain comprehensive guidelines for staff regarding individuals personal preferences about how they are guided, supported, moved and transferred. As at the previous inspection evidence indicates that people living at this home have access to a range of specialist community services should they require them. These include general practitioners, opticians, chiropodists, speech and language therapists and psychologists. The home uses a monitored dosage system for administration of medication and a sample of policies were viewed and found to be appropriate. Since the last inspection all of the requirements identified in the previous inspection relating to medication have been met. For example consent to medication Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 15 being administered has been obtained from residents relatives, up to date medication profiles are now in place for all individuals and the majority of staff have either completed or are in the process of undertaking accredited medication training. Some further improvements to medication are required to ensure systems safeguard those living at the home. For example none of the prescribed creams were dated when opened, there was excessive stock of some medication and other lotions were stored past their expiry date. It was pleasing to find that as well as training the home completes competency assessments. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have a good understanding of supporting people to raise concerns. Improvements to some protection policies, practices and procedures are required to ensure people are not at risk from harm and their rights are protected. EVIDENCE: All three relatives questionnaires received by CSCI prior to the inspection states that they have been informed of how to make a complaint about the care provided by the home if they need to and that the home responds appropriately if concerns are raised. Information supplied by the home prior to the inspection states that there has been three complaints since the last inspection, all substantiated and responded to within 28 days. The home has a complaints system with timescales for response. Prior to the inspection the CSCI received a copy of a complaint that was sent directly to the home. No record of this was found on the homes complaint file and the home did not notify CSCI of this in line with Regulation 37 of the Care Home Regulations 2001. This was discussed with the proprietor and registered manager who were instructed to review the current recording system for complaints to ensure it fulfils legal obligations and ensures that systems safeguard those living at the home. It is also recommended that further work be undertaken to improve record keeping in this area, as records do not evidence action taken and outcomes for all complaints on file. It is very encouraging to see that staff can access the complaints system and have raised complaints on behalf of residents, which is commendable. All staff that were interviewed demonstrated understanding regarding their responsibilities to support people who may be unhappy. As one person explained, “ I would go and talk, sit at Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 17 their level, try and calm down, because they don’t communicate verbally you have to try and think what they going through”. The home also maintains a record of compliments received. This includes thank-you cards from relatives and other interested parties. As at the previous inspection there are a number of safeguards in place to protect residents from abuse including a robust recruitment and selection procedure for new staff. Staff have received training in vulnerable adult abuse. During interviews they demonstrated good knowledge of the principles of protection and gave correct responses to how they would deal with any potential incidents of abuse. For example one person explained, “watch for signs, monitor and report, take straight to manager”. Since the last inspection the home has obtained a copy of the Department of Health guidance on the Protection of Vulnerable Adults (POVA) scheme but is still to amend the vulnerable adult policy to include the new POVA guidance. A ‘management of violence’ policy dated December 2002 is in place that includes instructions for maintaining records and training for staff. During discussions with staff particular time was spent ascertaining their understanding of behaviours that may challenge them and aggression. All staff that were spoken to discussed the needs and actions of one particular person despite others living at the home displaying behaviours and receiving specialist input. Although there is some evidence that indicates attempts are being made to support this person such as the home requesting help from outside agencies, other evidence leads to the conclusion that their needs are not being met in this area. Some staff understood how to support this particular person, for example explaining “try to find out what causing behaviour first, and remove either the object or person away, try to calm situation down as best as we can. Hopefully they will calm down, don’t tell certain person they are naughty but get them to try to understand what they are doing” but others did not. For example one person stated, “one likes to be centre of attention. If finished their meal they will try taking tablecloth off even if others eating, its like they are saying I’m here, I’m finished. Does it a lot to get out attention”. This particular situation was discussed with the proprietor, with the inspector asking why everyone has to eat their meal at the same time and cannot leave the table despite this situation appearing to result in behaviours being displayed. The proprietor explained that this routine is in place due to many people who live at the home requiring one to one staffing at mealtimes. As mentioned earlier in this report the home must explore other arrangements at mealtimes. Protection and behaviours that may challenge were discussed with the proprietor and registered manager who were advised to obtain the CSCI guidance ‘Cornwall Enquiry Recommendations’ and ensure practices reflect the recommendations to ensure people living at the home are protected from harm. It is also recommended that the home obtain the Department of Health’s ‘Guidance for Restrictive Physical Interventions’ again to ensure practices within the home protect those living there. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 18 None of the people who live at this home are able to manage their finances independently. The records and finances of three people were examined and found to be accurate. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe and comfortable environment that encourages independence. EVIDENCE: A tour of the premises was undertaken. Since the last inspection a bedroom has been redecorated and another been provided with new furniture. A previous requirement to improve accessibility for wheelchair users into the garden area from the main lounge and bedrooms by providing more suitable ramps/adaptations has also been met. All bedrooms are decorated and furnished to a high standard and individualised with personal possessions, photographs and stereo equipment. It is pleasing to see that colour schemes, décor and furnishings reflect resident’s individual tastes. It was suggested to the registered manager that signage be investigated for identifying glass in the patio windows located in residents bedrooms in order to promote the health and safety of individuals. When assessing the environment the inspector found that the floor in the hallway is damaged and uneven. The proprietor states this is going to be repaired when the residents are on holiday in July, in order that access can be gained and safety maintained. It is recommended Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 20 that a risk assessment be completed until such time the work is carried out in order that any risks are identified and appropriately managed, safeguarding those living at the home. A sensory room located in an outbuilding is currently out of commission, with the registered manager explaining this is due to concerns with electrics. She explained that this should be addressed by the end of the summer. The home has two bathrooms, both of which are located near to resident’s bedrooms. One has an assisted bath and the other a spa bath. When touring the home the inspector found communal towels in one of the bathrooms. The registered manager confirmed that the use of communal towels does not support person centred approaches to care and agreed to cease this practice. The kitchen was seen to be well stocked and clean. The homes laundry was viewed and found to be appropriate. The registered manager was advised to introduce written procedures and systems for the sanitizing and storing of mops to ensure good infection control practices are maintained. It is also recommended that the home obtain the revised Department of Health guidance ‘Infection control Guidance for Care Homes’ to ensure its systems comply with current good practice. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are deployed in sufficient numbers to support the people who live at this home. Improvements to some specialist training will provide staff with the necessary skills and knowledge to meet the needs of some individuals. People who live at this home are protected from harm by its recruitment procedures. EVIDENCE: Information supplied by the home prior to the inspection states that since the last inspection the staff complement has increased to meet needs of residents, resulting in twenty two staff being employed, eleven with National Vocational Qualifications at level two or three. Information also states that since last inspection staff have undertaken medication, learning disability award framework accredited training, deaf awareness, dealing with difficult situations, equal opportunities, person centred planning awareness, autism and continence awareness training. It details future training as pressure care, diabetes, epilepsy, mental capacity act, continence and palliative care. The inspector instructed that further work be undertaken with regards to understanding challenging behaviour, communication and epilepsy as evidence gathered from discussions with staff and other professionals, observations of practices and examination of records indicates that some Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 22 staff do not have sufficient knowledge in these areas to support people living at the home (as evidenced in other sections of this report). Four staff files were viewed in order to see if the home recruitment and selection practices safeguard people living at the home. Of those files seen all of them contained an application form and suitable written references, it was also pleasing to see that checks such as the PoVAfirst and Criminal Record Bureau disclosures were in place ensuring people living at the home are protected from harm. It is recommended that the home review its application form, as this currently does not ask for details of full employment history or for explanations in gaps in employment. This would offer further protection to people living at the home. Of the four staff files sampled all contained evidence that staff receive regular, formal supervision in order that they can perform their duties and support people living at the home. In addition to this regular staff meetings take place, again as aids to supporting staff to fulfil their roles. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements to quality monitoring systems should take place to ensure people living at the home can be confident it is achieving its aims and objectives and that people are assured their views and opinions are not only listened to but also acted upon. Practice employed by management and staff actively promotes service users’ health, safety and welfare. EVIDENCE: Mrs Lynne Strudley is the registered manager of Conway House. She is qualified and competent to run the home. She has completed her Registered Managers Award and is currently undertaking a degree in social care with the Open University. Mrs Strudley does not hold the National Vocational Qualification level 4 in care. It is recommended that clarification be sought with CSCI central registration team regarding management qualifications and the guidance issued on the CSCI Internet relating to management qualifications be obtained. Everyone that was interviewed complimented the Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 24 manager and proprietor stating that the management of the home is good. As one person explained, “the management is very good, they are very understanding if you have personal problems, they are approachable, we have staff meetings, they listen to you”. The home is still required to implement quality assurance procedures and systems, including obtaining and recording the opinions of residents, friends, relatives and visitors. Monitoring of many aspects of the service takes place such as staff supervisions, Regulation 26 visits, care reviews and health and safety checks. The registered manager and proprietor confirmed that the views of families are sought but not of other stakeholders. They also confirmed that the views of staff are obtained through their annual appraisals and within staff meetings. As yet no system is in place for collating the views of people, analysing and incorporating into the homes business plan. Improvements to quality monitoring systems should take place to ensure people living at the home can be confident it is achieving its aims and objectives and that people are assured their views and opinions are not only listened to but also acted upon. Regulation 37 notifications have been forwarded to CSCI on a number of occasions for events such as people having to attend the accident and emergency unit at a local hospital. Evidence gathered before and during the inspector indicates that further work must be completed in this area to ensure the home is fulfilling its legal obligations and safeguarding people living at the home. For example the home has not informed CSCI of all complaints, incidents of aggression or restraint. Information supplied by the home prior to the inspection states that the fire officer visited the home on 10/05/07, fire equipment was checked 02/05/07, most recent fire drill occurred 28/03/07, staff received fire training 27/04/07, fire alarms are tested weekly, the central heating was checked 22/03/07, a Legionella check is completed weekly and six monthly water analysis undertaken and emergency lighting systems are also checked weekly. A random sampling of records during the inspection confirmed this information to be accurate. During discussions with staff several raised concerns regarding the staffing ratios during the night. For example one person stated, “nights we have one wake night and one sleep-in, I think we should have two for safety of staff and for residents. If anything happens while down here, the sleep-in might not hear and there have been instances of intruders in garden” and another “some night staff have trouble with certain ladies, when only one on its a bit daunting when having to lift and roll and change during the night, plus for security reasons during the night”. It is recommended that a system be introduced for monitoring the night staffing situation to ensure the health and safety of those living and working at the home is not compromised. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X 2 3 X Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement To ensure care plans are implemented for all identified needs in order that the risk of needs not being met is reduced (e.g. behaviour, communication and diabetes). Behaviour charts (ABC’s) must be completed for all incidents (as detailed in daily records) in order that the appropriate support can be given to individuals and their needs managed. The home must ensure prescribed creams are dated when opened, excessive stock of medication is reduced no medication is stored past its expiry date to ensure systems safeguard those living at the home. The home must maintain a record of all complaints to ensure it fulfils legal obligations and that systems safeguard those living at the home. The homes vulnerable adults policy must be updated to include information from National and Local authority and give clear guidance to staff of DS0000004821.V330235.R01.S.doc Timescale for action 01/08/07 2 YA6 15 01/06/07 3 YA20 13(2) 01/06/07 4 YA22 22 07/06/07 5 YA23 13(6) 01/08/07 Conway House Version 5.2 Page 27 6 YA23 13(6) 7 YA32 18(1)(a) 8 YA39 24 9 YA41 37 their responsibilities in reporting suspected abuse, offering greater protection to people. Requirement originally made 2005. To review and amend the aggression and restraint policy to ensure it complies with relevant legislation and protects people who live at the home and staff from risk of injury or harm. To ensure sufficient numbers of staff receive training in areas such as challenging behaviour, communication and epilepsy to ensure people who live at the home receive the required support to meet their needs. To make improvements to quality monitoring systems so people living at the home can be confident it is achieving its aims and objectives and that people are assured their views and opinions are not only listened to but also acted upon. Requirement originally made 2005. To ensure notifications in line with Regulation 37 of the Care Home Regulations 2001 are completed in order that people living at the home are safeguarded by the homes practices. 01/08/07 01/09/07 01/09/07 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations To produce care plans in suitable formats in order that individuals care be involved in decisions relating to their DS0000004821.V330235.R01.S.doc Version 5.2 Page 28 Conway House 2. YA6 3 4 5 6 YA9 YA14 YA17 YA17 7 8 YA22 YA23 9 10 11 YA23 YA24 YA24 12 13 YA24 YA30 care. That further guidance be given to staff with regards to communication aids as detailed in care plans and guidelines issued by outside specialists in order that they can be confident of being able to communicate with individuals living at the home. That assessments of risk be completed for all identified needs to reduce and manage the risk of harm to people. That the home improves its activity records in order that they demonstrate people living at the home lead full and active lives based on their needs and capabilities. That the home is able to demonstrate that the cessation of offering a choice at mealtimes is in the best interest of all residents. That the home reviews the current system of everyone having to eat together and waiting for others to finish eating before being able to leave the area in order that person centred approaches to care and support are promoted. To include evidence of action taken and outcomes for all complaints so that systems safeguard those living at the home. To obtain the CSCI guidance ‘Cornwall Enquiry Recommendations’ and ensure practices reflect the recommendations to ensure people living at the home are protected from harm. To obtain the Department of Health’s ‘Guidance for Restrictive Physical Interventions’ to ensure practices within the home protect those living there. That signage is investigated for identifying glass in the patio windows located in residents bedrooms in order to promote the health and safety of individuals. That a risk assessment be completed for the faulty flooring in the hallway in order that any risks are identified and appropriately managed, safeguarding those living at the home. That the use of communal towels ceases to support person centred approaches to care. To introduce written procedures and systems for the sanitizing and storing of mops to ensure good infection control practices are maintained. That the home obtain the revised Department of Health guidance ‘Infection control Guidance for Care Homes’ to ensure its systems comply with current good practice. That the home reviews its application form, as this currently does not ask for details of full employment history or gaps in employment. This would offer further DS0000004821.V330235.R01.S.doc Version 5.2 Page 29 14 YA34 Conway House 15 YA37 16 YA42 protection to people living at the home. That clarification be sought with CSCI central registration team regarding management qualifications and the guidance issued on the CSCI internet relating to management qualifications be obtained in order that the manager ascertain if her qualifications are appropriate for her role. That a system be introduced for monitoring the night staffing levels to ensure the health and safety of those living and working at the home is not compromised. Conway House DS0000004821.V330235.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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