Inspection on 29/11/05 for Conway House

This inspection was carried out on 29th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 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 29/05/07

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 Jayne Fisher Announced Inspection 29th November 2005 09:30 Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Conway House Address 44 George Road Oldbury West Midlands B68 9LH 0121 552 1882 0121 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.V259778.R01.S.doc Version 5.0 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 9th June 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 and a drying bench. 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.V259778.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted between the hours of 9.30 a.m. and 3:45 p.m. by two inspectors. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: case tracking, formal interviews with the manager and three support staff who were on duty. There was also a tour of the premises. All residents (with one exception) were at home during the day as due to bad weather external day care provision had been cancelled. Formal interviews were not appropriate therefore inspectors relied upon observations of body language, eye contact, gestures, responses and other observations of interaction between staff and service users. A number of records and documents were also examined. Feedback was received from three relatives who completed questionnaires. Service users appeared comfortable in their surroundings and the home presented a relaxed and happy atmosphere. The overall inspection findings confirmed that staff are maintaining exceptionally high standards of care and are making genuine efforts to meet any outstanding requirements. Conway House is a home that provides care for persons who may have profound and multiple learning disabilities and other associated complex needs. A number of standards were examined at the last inspection and this report should therefore be read in conjunction with the previous inspection report to give an comprehensive overview. The inspectors were made to feel very welcome and would like to thank service users and staff for their hospitality and co-operation during the visit. What the service does well: Staff fully understand residents’ rights to dignity and privacy which are recurring themes in all elements of care planning and care delivery. Daily routines are flexible and geared towards meeting individual residents’ needs for example with regard to getting up and going to bed times. Residents are encouraged to make their choices and aspirations known through a variety of strategies. For example a range of food options are provided at each meal time and staff observe body language and gestures in order to determine preferred choice. Meals are varied and specialist diets catered for. Mealtimes are relaxed and unhurried with staff making this a sociable and enjoyable event. All families stated that they were made very welcome when visiting the home and staff make concentrated efforts to support residents in maintaining important relationships. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 6 Staff encourage residents to maintain and develop social, emotional, communication and independent living skills through a variety of stimulating and therapeutic day care activities. There are good links with the local community and residents participate in a number of outings and community based activities during the week. There is excellent promotion of health care and as a result any potential problems are quickly identified and dealt with. Residents are protected from abuse, neglect and self-harm through a number of strategies employed by staff. There is a competent and skilled staff group to support residents, with the manager placing a strong emphasis on training. Staff demonstrate dedication and a caring approach to their responsibilities. Positive interaction between staff and residents was observed through out the inspection. Residents benefit from an extremely well run home by a conscientious and knowledgeable manager who along with her staff team are strongly committed to raising standards and maintaining a high quality service. What has improved since the last inspection? What they could do better: A small number of items require attention. For example, there are very good procedures relating to the management of residents’ finances. As the owner is the appointee for some residents the existing independent audit should be expanded to cover all aspects of residents’ monies. Record keeping in respect of monitoring and evaluation of day care activities needs to be more consistent. Residents receive hourly checks during the night time which may not be necessary for all residents and requires review. A copy of the new guidelines with regard to the Protection of Vulnerable Adults scheme needs to be obtained. Feedback about the service from relatives and professionals needs to be sought to assist with the on-going development and review of the service. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 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: Although there have been no new admissions since the last visit a previous recommendation to introduce a comprehensive assessment tool in order to periodically reassess existing service users has been fully complied with. On examination this is an holistic document which covers all of the subjects required by the National Minimum Standards. It was pleasing to see that all existing residents have been re-assessed using this document which is an aid in measuring whether current needs have changed or are being met. Since the last inspection the statement of purpose has been amended as required. There are terms and conditions of occupancy which are contained within the service user guide. Each service user has an individual copy which is excellent practice. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Staff support residents to make decisions about their lives through a range of strategies thereby enabling them to have control over how their care is delivered. EVIDENCE: Care plans and risk assessment were examined as part of case tracking and in order to determine if outstanding requirements had been met. Staff are to be congratulated on the efforts made to improve care plans. These are extremely detailed and all aspects of care are now covered. There are very detailed guidelines for staff to follow in delivering complex care packages. During interviews it was pleasing to see that staff demonstrated a knowledge of care plans. Risk assessments have also now been improved and cover all subjects. There is good progress towards introducing essential life style planning and life story books as person centred planning approaches. This enables residents to participate in how their care is delivered and make their wishes and aspirations known. At present staff are awaiting assistance from speech and language therapists who are introducing communication passports to assist in this process. Families are also being involved in building life story books. The manager is becoming a person centred planning facilitator with the Local Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 11 Authority and with the assistance of a co-ordinator will be further progressing this aspect of care. Staff support residents in decision making through various strategies including person centred planning. As well as developing communication packages to assist in this process, staff have devised creative measures for example providing two choices for meals and observing body language as to which food option is preferred. The manager has obtained details of advocacy services which can be accessed if necessary. All families who completed the preinspection feedback forms confirmed that they were consulted about their relatives’ care and there was evidence in case files to confirm that they were invited to care plan reviews. Residents are not able to manage their own finances. There are detailed care plans in place as to how they are supported. All residents have appointees with regard to managing their finances. The Registered provider remains appointee for three service users at the express wishes of families. The manager reports that the proprietor brings service users’ personal allowances and other benefit monies to the home on a weekly basis; they are not held in a central bank account by the provider, as is good practice. New guidelines have been issued by the Commission for Social Care with regard to corporate appointees. Although all monies and records are audited on an annual basis by independent accountants this does not extend to residents’ personal allowances. As discussed, it is recommended that this is extended to ensure this aspect of residents’ monies is also included to further enhance existing systems. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Service users are assisted to participate in a range of leisure and social activities in the home and in the community, which is 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. Daily routines are operated on the principles of choice and respect. The home provides a well balanced diet offering choice and variety. EVIDENCE: Staff provide an in-house day care service to four residents; four residents receive external day care. Interviews with staff and examination of records demonstrate that activities which are provided are stimulating and therapeutic. On the day of the inspection residents were involved in a variety of arts and craft sessions. Activity programmes are planned on a weekly basis; these include food and personal shopping, going to the cinema, pub lunches, arts and crafts, sessions in the sensory room, going to church, foot spas and pampering sessions. There is a useful day care ‘folder’ which is also a resource folder and includes comprehensive profiles of individual residents’ preferences to assist staff in planning activities which is commendable. Although the is a sensory room on the premises residents can also access external sensory Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 13 facilities. There is a range of sensory equipment in the sensory room and in communal areas and residents’ individual bedrooms. There is only one aspect which requires improvement in what is an otherwise excellent service. Staff are not always completing daily ‘response’ sheets. These are activity monitoring and evaluation sheets which should be completed after every activity. These are important particularly as daily reports systems do not always include mention of what activities have been provided. On case tracking the weekly activity plan is not always followed and although interviews with staff confirms legitimate reasons why other activities were provided, the completion of evaluation and monitoring forms would assist in confirming why alternatives are offered. In addition there is no activity plan for weekends. During interviews the manager felt this was unnecessary because of the spontaneity of weekend activities. It is clear from examination of records that staff are more than competent and motivated to organise activities at weekends to suit residents’ preferences and wishes. As a compromise it was suggested that daily response forms could be completed at weekends in order to demonstrate what activities have been undertaken during that period. There is an outstanding requirement with regard to providing funding for residents’ annual holidays. Records and interviews confirmed that good progress is being made. At present management are awaiting confirmation from the Local Authority as to what constitutes a fair sum of money to contribute. Staff continue to strive hard to include families in important aspects of service users’ lives and build positive relationships. All relatives commented that they were made to feel welcome when visiting the home. Any concerns raised are dealt with in a proactive manner. For example one relative had raised issues via the inspection form and this was raised directly with the manager. A positive response was received and examination of records evidenced that appropriate action had already been taken to address some issues. Daily routines are operated around service users’ individual needs and wants. During interviews staff gave excellent examples of how they promote residents’ dignity. It was extremely pleasing to see that goals and objectives contained within care plans all contained elements of how dignity should be promoted in all aspects of care which is commendable and demonstrates sensitivity and insight by staff. Service users have unrestricted access around the home and there is evidence contained within care plans of how independent living skills are encouraged (which was also confirmed during staff interviews). All relatives who completed feedback forms confirmed that they could see their family member in private if they so wished. The home provides a good balanced menu. Choice and variety are given to service users; both the manager and staff demonstrated clear understanding of the needs of service users with regard to their individual needs, diets and Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 14 how to offer choices. A lunch time meal was observed. Time had been taken by staff to make the dining room look attractive. Service users had a variety of different meals for lunch and it was pleasing to see staff eating their meals with residents promoting a congenial atmosphere. Those residents requiring assistance were helped by staff in a professional manner. A range of condiments were available for residents to enjoy their meal as is good practice. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Personal support is offered in such a way as to promote service users’ privacy and dignity; only one aspect needs review to promote this further. The health needs of service users are well met and careful monitoring helps identify any potential complications at an early stage ensuring service users’ receive the treatment they require. The systems for administration of medication are good with clear and comprehensive arrangements being in place to ensure service users’ medication needs are met. EVIDENCE: Assessments and care plans contain comprehensive guidelines for staff regarding service users’ personal preferences about how they are guided, supported, moved and transferred. For example, one care plan covered specific details of how the resident liked to have their hair groomed, nail care, personal hygiene and oral care attended to, as already mentioned all goals and objectives identified, contained themes regarding dignity. Records contained details of residents’ preferred getting up, going to bed and bathing times. During interviews staff were knowledgeable regarding residents’ preferred routines. There is a range of technical equipment provided in order to aid independence including portable hoists, specialist baths and showers. (See further comment in standard 24). Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 16 It was ascertained that residents receive hourly checks during the night time. Whilst it is acknowledged that staff are doing this for genuine reasons and are understandably anxious that residents are checked and monitored; consideration must be given as to what this level of monitoring will achieve and whether this is a restriction upon residents’ rights and a disruption to sleeping patterns. It was reassuring to learn that staff were already planning to review this practice. Assessments should be undertaken and decisions made based on clinical good practice. Outcomes should be recorded in individual care plans, and risk assessments carried out (if this level of monitoring is necessary). It may be helpful to liaise with other professionals. Interviews with staff and management confirmed that high standards are being maintained with regard to promoting health. This was also confirmed on case tracking. For example, staff have proactively sought the help of psychology and psychiatrists in helping with one resident’s challenging behaviour. Staffing levels are increased and applications for extra funding are being applied for. Some residents are prone to pressure sores. There are comprehensive care plans and risk assessments in place. A range of pressure relieving equipment is provided. Support is accessed from other professionals as and when necessary. It was pleasing to see that physiotherapists had been involved in one residents’ skin care and positioning. As a result photographic ‘postural care guidelines’ had been produced. This is an exceptionally useful tool in demonstrating how the individual resident should be positioned at night time in respect of health and safety and tissue viability. The manager reported that a second resident will be receiving the same assessment and support. Tissue viability training is planned for the near future. There is good health care screening in place and care plans contained goals and objectives with regard to breast, cervical and testicular screening. Menstruation and bowel charts are used. Since the last inspection nutritional care plans have been established for residents with eating difficulties and who require extra monitoring. Care plans contained up to date nutritional screening. Service users are weighed on a regular basis; difficulties are sometimes experienced because wheelchair users have to rely on accessing external facilities. Further advice was given regarding alternative measurement tools. It was pleasing to see that the manager has contacted the community dietician to seek further general advice and is awaiting an appointment. Very good progress has been made towards improving procedures in respect of the control and administration of medication. It is evident that the manager and designated staff have worked hard to address and have greatly improved the majority of requirements made at the last inspection. All written guidelines and procedures are now in place. Staff are now undergoing the safe handling of medicines training with Dudley College. Designated staff are responsible for the administration of medicines. Signatures and initials of staff are kept on file. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 17 Accurate records are now kept for the receipt and disposal of prescribed medication. However there is no system for the receipt of household remedies; this was discussed with the manager and staff on duty and a system of recording the receipt is to be implemented. (This must include over the counter bought creams and ointments, if used). The storage, administration and receipt of controlled drugs are recorded but quantities of tablets stored in cabinet need to incorporated in the recording. Individual records should be kept for service users. The pharmacist now visits the home quarterly. Inspectors discussed with the manager the need to obtain consent to medication on service users’ files. It was suggested that the lack of capacity to consent be discussed at the forth-coming statuary reviews with professionals and families involved. Medication received in bulk must be individually labelled as once outer wrapping has been removed all instructions form pharmacy is lost. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home is making good progress in ensuring policies, procedures and practice offer residents robust safeguards from abuse. EVIDENCE: 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 Whistle Blowing and gave correct responses to how they would deal with any potential incidents of abuse. The manager is committed towards protection of vulnerable adults and commendably has obtained vulnerable adult protection procedures from both Sandwell and Dudley Local Authorities. Recruitment and selection practice demonstrates that management have a good understanding of the Protection of Vulnerable Adult Scheme which was introduced last year. A copy of the Department of Health guidelines must also be obtained and the home’s own vulnerable adult abuse policy accordingly updated with the new guidelines and procedures. On examination there are good procedures relating to the handling of residents’ monies. Records and monies were sampled which balanced accurately. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were fully assessed at the last inspection. EVIDENCE: An evaluation took place to determine if improvements required at previous visits had been undertaken. A tour of the premises confirmed that all items had been addressed. For example carpets had either been replaced or cleaned again. Staff now report that they encounter no difficulties when assisting wheelchair users to access the garden via the lounge and small ramp provided. There is a requirement to provide ramps to bedrooms where the garden can be accessed via patio doors. The manager reports that portable ramps have been decided upon and will be obtained in the future. It was also pleasing to see that improvements have been made to infection control practice. For example staff have received training and clinical waste bins have been fitted with locks. There is only one outstanding item which is with regard to the installation of overhead tracking devices to promote dignity when hoisting residents and also improve safety aspects. Staff report that they think this was discussed previously and decided against because of structural issues. There was no evidence to demonstrate on what basis this decision had been reached. The recommendation will therefore remain outstanding. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 35 Service users are supported by competent and qualified staff. Through comprehensive induction programmes new staff are given the underpinning knowledge to meet residents’ specialist needs. EVIDENCE: The home is exceeding the national minimum standards with regard to the amount of staff who have achieved NVQ qualifications. Seventeen support staff are employed, eleven of whom are qualified to NVQ II or above which is commendable. Specialist training is on-going with staff receiving training in autism awareness, incontinence management and the majority of staff have receiving training in epilepsy awareness. Some staff have received training in ‘dealing with difficult situations’ which is a training course dealing with violence and aggression. On examination of the training programme it is suggested that more specialised training with regard to understanding challenging behaviour and people with learning disabilities would be more beneficial, as this would give staff a more in depth understanding of good practice and legislative requirements including methods for dealing with varying behaviours. Very good progress has been made with regard to ensuring that induction and foundation programmes are offered which are provided by accredited learning disability award framework providers. To aid this process the manager has been trained as a marker and three more senior staff are going to be trained in Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 21 the near future. As well as new staff undergoing this training, existing staff are also going on refresher training which is an excellent initiative. Interviews with new staff confirmed that they found this training insightful and beneficial in providing them with the knowledge in delivering specialist care. All staff have received training in equal opportunities and disability awareness. There is a comprehensive training programme and individual training profiles for staff. Since the last inspection, the manager has completed a comprehensive staffing assessment in order to demonstrate how staffing levels meet the needs of residents as requested. Examination of personnel files for new staff confirmed that health care questionnaires have now been introduced and copies of job descriptions are held on files as is good practice. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 42 The manager provides clear leadership throughout the home with all staff Practice demonstrating an awareness of their roles and responsibilities. employed by management and staff actively promotes service users’ health, safety and welfare. EVIDENCE: Service users benefit from a well run home. The Manager demonstrates considerable knowledge regarding their individual needs and the findings of this inspection confirm that she is dedicated to raising standards and maintaining a high quality service. The manager places a strong emphasis on training for staff and herself. This is enhanced further by the manager who frequently monitors that staff understand policies and procedures and that training which has been given is continually applied. This is commendable. It is refreshing to find that the manager continually updates her knowledge and knew about impending changes to regulation. Mrs. Strudley is planning to undertake a number of further qualifications including an NVQ IV in care and a Health and Social care degree with the Open University. All staff were complimentary with regard to the management style operated by Mrs. Strudley Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 23 whom they felt was approachable and supportable. Comments included: “she’s brilliant, she helped me when I got stuck on the induction programme”. “I can take any personal problems to her”. As identified at previous inspections quality assurance systems need further improvement. The manager is looking at various strategies for entering into meaningful engagement with relatives and other stakeholders. There are good strategies for promoting health and safety within the home. For example all staff have received the required mandatory training. Annual fire training has been provided and the manager has supplemented this by regular refreshers (which need to be recorded). If the manager is to undertake fire training with staff it may be beneficial to attend management training in fire safety. All previous requirements with regard to fire safety, health and safety and food hygiene have been fully met. A recent inspection took place in October 2005 by the Environmental Officer. Food hygiene practice was deemed to be excellent and makes the home eligible for a ‘Eat Good Hygiene Award’. A number of maintenance and service records were sampled which demonstrated good health and safety practice. For example, there is regular checking of water temperatures, wheelchairs are annually serviced and there are interim maintenance checks. Bedrails are regularly checked and records maintained. There is excellent accident reporting systems. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Conway House Score 2 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 x DS0000004821.V259778.R01.S.doc Version 5.0 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1) Requirement To produce a service user plan in a format suitable for service users. (Previous timescale of 1/1/05 is partly met). To introduce an essential life style planning format and life story books. (Previous timescale of 1/1/05 is partly met). To provide an annual seven day minimum (or shorter breaks if more appropriate) holiday, for service users which is included as part of the basic contract price. (Previous timescale of 1/1/05 is partly met). Timescale for action 01/04/06 2. YA14 16(2)(n) 01/10/05 3. YA18 12(4)(a) To more consistently complete daily ‘response’ record sheets and evaluations with regard to day care activities. To include written explanations for any deviation from daily activity plan. To progress plans to review 01/02/06 practice of hourly night checks for service users. Care plans must be updated accordingly with outcomes of individual reviews. If this level of DS0000004821.V259778.R01.S.doc Version 5.0 Page 26 Conway House 4. YA20 13(2) monitoring is deemed necessary, individual risk assessments must be carried out to demonstrate why these levels of monitoring are required. To provide the Commission for 01/03/06 Social Care Inspection with an action plan to improve the control and administration of medication in the following areas: 1) To ensure that consent is obtained to medication from each service user and recorded in the care plan (or to acknowledge if this is not possible). (Previous timescale of 1/6/05 is not met). 2) To ensure that there is an up to date medication profile contained within individual care plans. (Previous timescale of 1/9/05 is not met). 3) To pursue training in the safe handling of medication for staff with an accredited trainer (Previous timescale of 1/9/05 is partly met). 4) To ensure that where medication is dispensed in multipacks (such as Fybogel sachets) that each box is labelled with the name of the individual service user and details of administration. 5) To ensure that a separate page is used per service user for the administration of Controlled Drugs in the Controlled Drugs book. A running balance must also be kept. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 27 5. YA23 13(6) 6) To ensure that receipt of household remedies into the home is fully recorded. To obtain a copy of the Department of Health guidance on the Protection of Vulnerable Adults (POVA) scheme. To amend the vulnerable adult policy to include the new POVA guidelines. To improve accessibility for wheelchair users into the garden area from the main lounge and bedrooms by providing more suitable ramps/adaptations. (Previous timescale of 1/10/05 is partly met). To provide all staff with training in understanding challenging behaviour. To pursue plans to ensure that the Registered Manager is qualified to NVQ IV in care by 2005. To review and further develop the quality assurance system to include stakeholder feedback. (Previous timescale of 1/6/05 is not met). To ensure that the business plan is expanded to include a financial plan with details of budgets, predictions and overheads. (Previous timescale of 1/1/05 is not met). 01/03/06 6. YA24 23(2)(b) 01/10/05 7. 8. YA32 YA37 18(1)(a) 18(1)(c) 01/03/06 01/01/06 9. YA39 24 01/03/06 10. YA43 25(1)(d) 01/10/05 Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 28 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. 2. Refer to Standard YA7 YA29 Good Practice Recommendations To ensure that the independent audit of finances is expanded to include residents’ personal allowances and benefits. To consider the installation of an overhead tracking system in two service users bedrooms who require the assistance of a portable hoist. Conway House DS0000004821.V259778.R01.S.doc Version 5.0 Page 29 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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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