Inspection on 15/08/06 for Fallings Heath House

This inspection was carried out on 15th August 2006.

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

Other inspections for this house

Fallings Heath House 14/04/08

Fallings Heath House 17/04/07

Fallings Heath House 20/11/06

Fallings Heath House 23/11/05

Fallings Heath House 03/06/05

Fallings Heath House 22/11/04

Fallings Heath House 05/07/04

Fallings Heath House 21/02/04

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

CARE HOME ADULTS 18-65 Fallings Heath House Fallings Heath House Walsall Road Darlaston West Midlands WS10 95H Lead Inspector Lesley Webb Unannounced Inspection 15th August 2006 09:30 Fallings Heath House DS0000033324.V307836.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 Fallings Heath House DS0000033324.V307836.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. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fallings Heath House Address Fallings Heath House Walsall Road Darlaston West Midlands WS10 95H 0121 568 6297 0121 526 7023 dudleys@walsall.gov.uk 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) Walsall Metropolitan Borough Council Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation report dated 10.12.04 may be accommodated at the home in the category LD(E). This will remain until such time that the service users placement is terminated. Date of last inspection 23rd November 2005. Brief Description of the Service: Fallings heath is a purpose built, single storey building which provides accommodation and personal care for up to 16 persons who have a learning disability with additional complex needs. It is owned by Walsall Metropolitan Borough Council. The home is located in Darlaston, on the outskirts of Walsall, close to a few shops, pubs, the post office and other amenities. The home is divided into three units, each unit having its own lounge, dining area and kitchenette. All bedrooms are single and there are no en-suite facilities. There is parking to the front of the building and an enclosed garden to the rear. It is proposed that services within the home will cease in 2006 and therefore no new service users are being admitted to the home. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days with the home being given no prior notice of the visit. During the visit time was spent talking to service users, interviewing staff, looking at records and observing care practices before giving feedback about the inspection to the acting manager. The people who live at this home have a variety of needs and communication barriers. This was taken into consideration by the inspector when case tracking 3 individuals care provided at the home. For example the people chosen consisted of both male and female, new and established service users, with differing communication needs and from various cultural backgrounds. Prior to the unannounced inspection information relating to the service was sent to the Commission for Social Care Inspection by the acting manager. This was also used when forming judgements regarding service provision. Information supplied includes fees charged which is £935.00 per week. By the end of the visit the inspector was concerned with the deterioration in some aspects of the service that have the potential to place service users at risk. A further unannounced inspection will take place to monitor practices and assess compliance with legislation, however if no improvements are made the Commission for Social Care Inspection may consider enforcement action. The inspector would like to thank service users and staff for their co-operation and assistance during the visit. What the service does well: By observing care practices and talking to staff the inspector is satisfied that generally staff have knowledge of their role as advocates in supporting people with communication barriers to complain. For example one member of staff stated, “they can’t so it’s about us observing and watching and if you think they not happy with something we must report, even if your wrong you must still report it”. Staff also appear to understand the different communication needs of service users. As one member of staff explained, “you have to look at facial gestures and changes in behaviour. Also must be aware that service users act differently with different staff, never assume anything”. The home should also be congratulated for the essential lifestyle plans (a form of person centred planning) that are in place. All those seen by the inspector Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 6 were very informative, were in pictorial and large print format and demonstrated that service users wishes and preferences had been taken into consideration. Many other documents are also available in pictorial format, as aids to communication. These include service users contracts of residency, some policies and procedures including complaints and many consent forms such as permission to manage personal finances, open mail and offering of keys to bedrooms. What has improved since the last inspection? What they could do better: There are several areas that the home must improve in. Firstly improvements to some medication practices must occur. These include ensuring covert and controlled drug medication practices comply with legislation, ensuring full and detailed complaints records are maintained and reviewing of records required by regulation to ensure they are accurate and up to date. Without improvements all of these issues have the potential to place service users at risk. In addition to the above the inspector is concerned with some practices seen during the visit. These include sensory rooms being locked without staff having access to keys resulting in service users not able to access this facility, staff using a sling hoist inappropriately (placing a service user at risk) and the lack of personal protective equipment for people entering the main kitchen. Further more the home must make arrangements to ensure that the homes transport is accessible to everyone living at the home, make arrangements for Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 7 all service users to have a holiday this year and must review its procedures for service users purchasing aids and adaptations from their personal finances and demonstrate that no service user is discriminated against. Also the home must take action to meet requirements in full that have been identified in previous inspections. Presently there are twenty-one requirements that need further action, some of which were first identified in 2002. Requirements outstanding include service user risk assessments; care plans for independent living, choices of activities, fire department recommendations, staff training and employment records and quality assurance. Other areas for improvement that were identified during this inspection include the need to review documents including the statement of purpose and service user guide, to expand service users care plans, to ensure behaviour and communication plans are in place, to ensure full and accurate records are maintained of meals taken by service users, to obtain the views of service users and their representative with regards to funeral arrangements and to obtain information relating to the assessed levels of need for each service user in order that the acting manager is satisfied the home is appropriately staffed. In relation to staff the home must make arrangements for staff to undertake regular fire drills, person centred planning and Learning Disability Award Frame-work accredited training. Health and safety issues that require attention include replacing worn and damaged garden furniture, regular cleaning of the sandpit and light covers in the kitchens, ceasing the practice of storing wheelchairs in the sensory rooms, ensuring all fire doors close appropriately and introducing monitoring systems for the use of equipment such as hoists and commodes. Also the home must cease the practice of storing food items in the laundry and COSHH items that are secondary dispensed must have the correct labelling along with the correct data sheets and risk assessments. 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. Fallings Heath House DS0000033324.V307836.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 Fallings Heath House DS0000033324.V307836.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to some information about service and the home are required to ensure service users understand services they can receive. EVIDENCE: A statement of purpose, service user guide and other information about the home is displayed at the entrance to the home. Upon inspection of these documents the inspector found that all require reviewing as all contain either incorrect or out of date information. For example the statement of purpose states admissions procedures for new service users despite the home not admitting anyone due to the planned closure and that holidays must be funded by service user (this conflicts with information in service user guide). Information is given to families and other people who act on behalf of service users due to people living at the home having severe communication difficulties. Information is available in picture and large print format in order that information is accessible to people who live at the home. Due to the home planning to close at the end of 2005 no new service users are being admitted and therefore Standards 2, 3 and 4 are not applicable. The inspector sampled residential 3 service users documentation. All 3 contained information relating to their specific needs including religious, medical and those associated with specific learning disabilities but the level of detail varied greatly. Before the inspection was undertaken CSCI was supplied Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 10 with information relating to the assessed levels of need for each service user living at the home. This information stated that each individual has ‘medium needs’, however when the inspector looked at records and undertook observations within the home service users appear to have varying levels of need for example with mobility, communication and personal care. No service users file contained specific information relating to their level of need and the acting manager was not able to supply this information, stating that she had followed old pre-inspection information but was not happy with this, agreeing that service users have differing needs and levels of support. The acting manager agreed to review this information and forward this to CSCI. The inspector case tracked 3 service users files that live in the residential unit. All contained a contract of residency in picture format that include information relating to fees and what’s not included such as medical requisites, hairdressing, clothing and insurance cover for personal items. Only minor amendments to these are required to ensure they comply with the Care Homes Regulations 2001. All staff that were interviewed were able to explain how they communicate with people living at the home. For example one person stated, “They all communicate differently. When I first came here I read the care plans. You get to know service users by looking at facial gestures and body language, they all communicate differently. Essential Lifestyle Plans also give lots of information. Its best to observe service users as they react differently to different staff”. Observations made by the inspector confirmed that staff attempt to communicate with service users by observing behaviours, facial gestures and body language. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this home. Some evidence indicates service users are involved in decisions about their lives, however improvements to recording systems will ensure they play an active role in planning the care and support they receive. EVIDENCE: The inspector sampled 3 service users files and all contained plans of care, however only one contained aims or goals to support these plans. The inspector recognises that work has been undertaken to include aims and goals in personal development plans (see standard 11) however the home must now develop all other care plans accordingly. Two of the files sampled also contained plans for behaviour/communication that state intervention plans and behaviour guidelines must be followed however these were found to be missing by the inspector (one contained a behaviour support team discharge report dated 2002 but no other documents). It was also noted by the inspector that one service users file states that all new staff should attend behaviours support training upon appointment and that they must read the guidelines in place (both of which little or no evidence could be found). However when Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 12 interviewing staff all were able to explain how they support these individuals when presenting challenging behaviour. When asking how they knew this information when it was not present on the service users files staff informed the inspector that it is displayed around the home. The inspector raised this practice with the acting manager when giving feedback at the end of the inspection due to possible breeches in confidentiality when visitors enter the home. The inspector was pleased to find that the 3 files sampled did contain Essential Lifestyle Plans (a form of person centred planning). All are very detailed and informative and have been reviewed within agreed timescales (apart from one that had not been updated to reflect the service users move to Fallings Heath). None of the staff that were interviewed were able to explain what person centred planning is, with all confirming that they have not attended training in this area. 3 requirements identified in the previous inspection are now part met resulting in many risk assessments now being completed based on service users individual needs and capabilities, including agreed review dates and many being reviewed within agreed timescales. When assessing risk assessment processes the inspector examined documentation relating to service users at risk from sunburn (this was chosen after a Regulation 37 notice was sent to CSCI informing of a service user attending accident and emergency unit due to sunburn). The acting manager stated that risk assessments are in place for all service users but was not sure if care plans had also been completed. The inspector sampled 3 files and found that none contained care plans and that the completed risk assessments were basic in terms of content, not based on each persons individual needs, do not include dates of implementation or dates for review. The inspector found of evidence that service users are consulted and involved in making decisions about their lives despite many having communication barriers. For example all files contained consent forms in pictorial and large print formats for a variety of things including staff opening mail and keys to bedrooms as well as some policies such as complaints and key worker roles. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Social, educational and recreational activities do not meet individual’s expectations. EVIDENCE: As in previous inspections particular attention was given to assessing the support service users receive to develop their independent living skills due to the planned closure of the home resulting in the majority of service users moving into supported living environments. Progress has been made to introduce specific aims and goals for individuals with a breakdown programme for each task however no evidence of outcomes or achievements was found on the day of inspection on any of the files sampled (partly meeting 2 requirements identified in the previous inspection). It was also noted by the inspector that all plans stated they should be reviewed in 3 months but that they had been reviewed at 6 months. Programmes viewed include tasks such as tiding of bedroom, preparation of food, preparing toast and dressing. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 14 The inspector could find no evidence that the home has improved its recording systems relating to service users activities (a requirement identified in the previous inspection), resulting in very little evidence to indicate that service users are offered and participate in a variety of in-house and external activities. For example one persons records state for the month of April that they attended a day centre, looked at magazines, listened to music and watched television and another’s that they relaxed on the sofa watching television, had a bath and make-up applied, did light exercises and one to one dancing with staff. During the visit the inspector witnessed 2 service users going swimming with staff stating this occurs weekly. When asked how many other service users participate in this activity the inspector was informed “just these”. When asked why no other service users undertake this activity no staff were able to give an answer. The inconsistencies with choices of activities offered to service users was further re-enforced when staff confirmed that only 2 service users have been on holiday this year, with no arrangements made for everyone else living at the home. The acting manager showed a folder to the inspector that has been implemented that contains pictorial symbols and photographs of activities that service users can participate in. This includes choices such as use of one of the sensory rooms located in the home, swimming, bowling, shopping, cinema and meals out. The inspector recognises this tool will aid service users to make choices in relation to activities but at present recording systems do not demonstrate choices are being implemented and that access to activities relies on staff and management taking the initiative to arrange and record when choices have been offered, carried out and declined. For example when observing care practices the inspector noted that all sensory rooms were locked (with staff on one unit unable to locate the key when requested by the inspector). The inspector discussed this practice with the acting manager who was unable to clarify why this practice was in place. It is noted that since the last inspection the home has now been provided with its own transport, however the inspector found that this is not suitable for everyone living at the home, as it has no tail-lift resulting in those people in wheelchairs unable to use this facility. Records viewed also confirmed that those unable to access the homes transport have to pay for alternative transport from their own personal funds. The inspector raised concerns regarding this situation when giving feedback to the acting manager as it appears to conflict with equal opportunities guidance. Again inconsistencies in recording systems result in the inspector being unable to state service users receive choices in relation to meals taken. Large and colourful photographs are used to aid communication with choices at mealtimes but diaries that are maintained on each unit are not being completed for each person on a daily basis. This is concerning as the majority of service users at the home have communication barriers resulting Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 15 in records being the only form of monitoring available. The inspector was however pleased to find that nutritional assessments are in place for everyone, with staff demonstrating some knowledge of their contents. For example one person stated, “Its about if having enough vitamins, appetite, food, if they lacking in iron, healthy eating, poor appetite”. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 16 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, 20 and 21. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Medication practices do not support the principles of respect, dignity and privacy. EVIDENCE: Since the last inspection the home has started to introduce self-medication assessments for service users based on each person’s individual capabilities and made improvements in followings its own policies and procedures, partly meeting 2 previous requirements. Further work must be undertaken to ensure assessments reflect practices, for example one persons self mediation assessment states he will administer own medication with staff assistance. Staff stated that he puts in own mouth when given tot of medication however the risk assessment does not reflect this practice. It is also pleasing to find that details of mediation reviews are now maintain in full. The inspector observed medication practices during the visit. Several concerns were identified. Firstly the inspector witnessed the covert administration of medication for some service users. No records including consent care plans or risk assessments could be found to support this practice. Concern regarding this was further reinforced when discussing this with the acting manager who stated it did not occur but that, “medication is Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 17 placed in service users mouths then they are given food to help them take it afterwards”. The inspector stated that this was not occurring and that she had witnessed staff disguising medication in food in the separate kitchen areas before taking it to service users and administering. Secondly the inspector witnessed staff signing the medication administration record sheets before they had given service users their medication. Concern regarding this was further reinforced as medication administration is witnessed by other staff on duty, none of which questioned this practice. Thirdly the inspector raised concerns regarding the management of controlled drugs. Currently these are recorded on loose-leaf sheets and stored in removable, lockable tins on each unit. Finally the inspector instructed that the home cease the practice of recording a service users tobacco intake on the medication administration record sheets, informing that these should be used for prescribed medication only. The inspector was however pleased to find that all prescribed creams were appropriate stored and labelled on the day of inspection. Staff demonstrated knowledge and understanding of service users physical and emotional needs and their responsibilities to ensure these are met. For example one person stated, “I check care plans, make sure doctors appointments are up to date, and reviewed when supposed to be. If dental appointments are due make sure appointments kept. Report anything of concern, get relevant specialists involved. It’s our responsibility to monitor their well-being and to be aware of their needs”. In relation to personal care the inspector was pleased to find that the views of service users and families have been obtained pertaining to choices of gender of staff assisting with personal care. Care practices were indirectly observed by the inspector and found to be provided respecting privacy and dignity. Service users records confirm that health care is generally well managed with evidence of appointments at dentists, chiropodists, psychiatrists, opticians, district nurses, and audiologists. In addition to this the home is currently implementing health action plans. Those that were viewed appear very person centred and informative. The home has policies for care of the dying and death. Of the 3 service users files sampled one contained funeral wishes and arrangements that had been completed with the involvement of the service users family. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. 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 the service. Staff have knowledge of service users rights to complain and protecting them from abuse. Complaint monitoring does not ensure service users rights are protected. EVIDENCE: When asking staff how service users with communication difficulties can complain everyone who was interviewed demonstrated knowledge of their roles as support workers in this area. Responses included, “they can’t so its about us observing and watching and if you think they not happy with something we must report, even if your wrong you must still report it” and “its my role is to complain for them. For example if they get food and don’t like it I must go to manager and tell to change”. Due to the communication barriers of many service users staff arrange unit meetings where service users and staff meet, in order that staff can speak on behalf of service users, raise concerns and take any action required. When assessing complaint records the inspector was concerned with the acting managers understanding in this area, incomplete records and poor monitoring. For example CSCI forwarded a complaint to the home in April 2006 for investigation however no record of this was in place with the acting manager stating she thought the paperwork for this was not required because it had been sent to the responsible individual for investigation. Two other complaints dated March and June 2006 were found (one made by staff working at the home regarding a service user purchasing their own mobility aids and the other by a relative of a service user questioning access to activities). Neither of these had been logged fully, including investigations and outcomes. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 19 The home has policies in place for dealing with abuse, violence towards staff, whistle blowing, and dealing with service users finances that follow Walsall Vulnerable Adult Policies. In addition to this the majority of staff have received training in adult protection. All staff that were interviewed demonstrated understanding of protecting service users from abuse. For example one person stated, “I would report it straight away. Confident to do this regardless of who it is, because if it was a member of my family I would expect it to be reported so should do same for service users”. Records confirm that the home has made one referral to the local adult protection team in line with their responsibilities, acting appropriately and safeguarding people living at the home. Financial practices were scrutinised. It was pleasing to find that all files sampled contained pictorial documents informing service users where their finances are kept and how they can access them along with risk assessments for self management (some require further development to ensure their reflect individual capabilities). Personal allowance sheets and corresponding finances were sampled with all being up to date and correct. When looking at financial management the inspector found that some service users have purchased aids and adaptations such as commodes and hoist slings from their personal savings. The inspector questioned this practice as the home has a responsibility to provide any equipment required to meet service users needs. Management stated that this had occurred because service users chose to purchase a better quality item than previously in place. The inspector instructed that the home must review its policies and procedures regarding service users purchasing items that the home is responsible for providing in order that a contribution is made by the home and that service users with little or no savings are not discriminated against. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvements to the environment must be made to ensure service users live in a safe, well-maintained and comfortable environment. EVIDENCE: 3 requirements identified in the previous inspection are now met in full (maintaining room temperatures, risk assessments and infection control policies and procedures) and one partly met (recommendations made by the fire department). The building does not meet many national minimum standards such as room sizes, shared facilities and aids and adaptations. However requirements relating to these are not included in this report as CSCI has agreed with the local authority a planned closure of the home and is only assessing comfort and health and safety issues relating to the environment. The inspector completed a tour of the building and found generally that the home is maintained to an adequate standard. Work is required to repair chipped paintwork throughout the home, replace the worn garden furniture, Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 21 clean the sandpit, clean all light covers in the various unit kitchens and to stop the practice of using the sensory rooms to store items including wheelchairs. Whilst touring the building the inspector observed that a hoist used for a named service user was not accessible as it was in a locked room with staff unable to locate the key. When asking how this impacted on safely manovering the named service user without equipment staff stated it was not needed. The inspector discussed this situation with management when feeding back findings at the end of the inspection instructing that records be implemented detailing how, who and when equipment was required for the named service user due to an assessment being in place stating a hoist was required. It was also noted by the inspector that many fire doors do not close appropriately, increasing the risk of smoke inhalation if a fire were to occur. Infection control practices were also examined. The home has a separate laundry room with all required equipment, including washing machines with disinfection programmes. Throughout the inspection no laundry staff were witnessed using personal protective equipment and when examining the laundry room food items were found to be stored there. The inspector instructed that these be removed immediately. Instructions were also given to decorate the sluice room and cease the practice of storing items in this facility due to infection control risks. Control of substances hazardous to health were viewed and generally found to be in order, apart from some items being secondary dispensed without the correct labelling and data sheets and risk assessments missing for a few items currently in use. The inspector also instructed that personal protective equipment be made available anyone entering the main kitchen, as none was available during the inspection. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are generally trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: The inspector was pleased to find that work has progressed to address many requirements identified in previous inspections relating to training and support. The majority of staff have now undertaken communication and equal opportunities training, individual training and development assessments have been completed for all staff and an impact assessment is now in place that identifies future training requirements. In addition to this regular staff meetings occur, with minutes maintained. Records of meetings show that staff meetings are very informative. Improvements to individual staff supervision have also taken place. Work must now be undertaken to ensure all staff either hold a NVQ level 2 or above, or be working towards achieving this. Four staff employment records were examined. The majority of records required by regulation were found to be in place, with only minor work required to meet this requirement in full. The inspector also case tracked 4 staff to see if they have the appropriate qualifications and experience to care for people living at the home. Certificates demonstrate that staff have received training in communication, behaviour, epilepsy, writing with symbols, Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 23 continence and care practices. Only 1 of the 4 files sampled contained evidence of LDAF training. All staff that were interviewed felt that they receive appropriate training in order to fulfil their responsibilities. Staffing rotas demonstrate that in general 6 care staff are on duty during the day along with a senior care manager. In addition to this domestic, laundry and kitchen staff are employed over a 7-day period. The inspector found that on some occasions care staffing had been reduced to 5, with the acting manager stating that this was due to staff telephoning in sick at very short notice resulting in the home unable to find cover. It was also noted that on some occasion’s staff rotas have not been completed in full (for kitchen staff), giving the appearance that no kitchen staff have been on duty after 12.30pm. The acting manager stated that this was not the case, that the kitchen is always fully staff, rather that the records were not accurate. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 24 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): 37,38,39,40,41,42 and 43. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management and administration of the home is poor with little evidence that effective quality assurance systems ensure continuous improvement. EVIDENCE: Since the last inspection a senior care manager has been appointed as acting manager. An application for registration is currently being processed for this person. The acting manager is in the process of completing the registered managers award and is going to undertaken the NVQ level 4 in care afterwards. Short courses that the acting manager has undertaken include stress awareness, safe handling of medication, adult protection, communication, leadership, equal opportunities and makaton. Improvements must be made to records management. As detailed throughout this report many records required by regulation were not in place, required updating or reviewing. The inspector was particularly concerned that the acting Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 25 manager had wrote to the families of service users stating that “the home remains in the distinction level” of service after the last inspection by CSCI in 2005. The inspector asked why she had miss-informed families, when the service had been assessed as amber (adequate). The acting manager stated that she used this wording as she thought using the colour coding might be confusing. The inspector instructed that amended correspondence must be sent to all interested parties. Quality assurance is still in the process of being developed. Since the last inspection the acting manager has obtained the views of service users and their representatives, forwarding an analysis to CSCI. These findings now require incorporating into a development plan for the home. An annual audit of the quality assurance system is still required (as identified in a previous inspection). A draft policy for annual development of the quality assurance system was shown to the inspector with the acting manager being advised to ensure this includes information relating to annual audits, development plans and analysis of service users views. The lack of a quality assurance system being fully imbedded at the home was further reinforced when interviewing staff, none of which could explain what quality assurance is and why it is important. Pre-inspection documentation supplied to CSCI by the acting manager states that a fire drill was completed in March 2006, however upon inspection of records for this the inspector found that only 9 of the twenty-nine staff employed at the home had attended with none of those in attendance being night staff. External fire training occurred in January 2006 with only 5 staff still requiring attendance. Other health and safety management was inspected and found generally to be adequate. Records confirm that equipment is serviced appropriately, services including gas and electric checked regularly and compliance with legionella maintained. A wiring certificate for the building could not be found. Previous requirements relating to mandatory safety training and reviewing the homes fire policies and procedures remain part met, with minor work required to meet these in full. In addition to these the home is still to arrange risk assessment training for staff and must review safe working risk assessments to ensure they cover all topics as listed in Standards 42.2 and 42.3 of the national minimum standards. The inspector did however instruct that all staff be retrained in appropriate use of equipment and moving and handling after witnessing a service user being hoisted from wheelchair to lounge suite with the sling inappropriately positioned under the service users arms resulting in the sling not supporting appropriately and potentially placing the service user from risk of falling or injury. Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 26 Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 2 30 2 STAFFING Standard No Score 31 3 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 2 LIFESTYLES Standard No Score 11 2 12 3 13 2 14 1 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 2 X X 1 3 1 2 3 Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 28 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 YA1 Regulation 4,5,6 Requirement The statement of purpose, service user guide and other information about the home must be updated. An assessment of needs must be made for each person with a record maintained on their file. A breakdown of each service users assessment level must be forward to CSCI. Service users contracts of residency must be completed in full. Care plans must cover all aspects of personal, social and health care needs. All care plans must include specific aims or goals. Behaviour and communication plans must be in place for all service users that have been assessed as requiring these (as stated in care plans). All staff must undertake person centred planning. Risk assessments must be completed for all service users DS0000033324.V307836.R01.S.doc Timescale for action 31/12/06 2 YA2 14 01/10/06 3 4 YA5 YA6 5(b) 15 31/12/06 31/12/06 5 6 YA6 YA9 12 13(4) 31/12/06 01/10/06 Fallings Heath House Version 5.2 Page 29 based on their individual needs and capabilities –Part met. Requirement originally made November 2005. Risk assessments must include agreed review dates - Part met. Requirement originally made November 2005. Risk assessments must be reviewed on the agreed review dates - Part met. Requirement originally made November 2005. 7 YA10 12(4) All service users personal records must be stored in line with the Data Protection Act 1998. The home must implement care plans for the social, emotional, communication and independent living needs of service users – Part met. Requirement originally made November 2005. Care plans must include specific aims; support needed by staff and agreed review dates - Part met. Requirement originally made November 2005. Evidence of outcomes and achievements for specific goals must be maintained. 9 10 11 YA13 YA14 YA14 12(1)(a) 16(m)(n) 16(m) The homes transport must be accessible to everyone living at the home. Service users must have ready access to the sensory rooms on a regular basis. Arrangements must be made for all service users to have a holiday this year. DS0000033324.V307836.R01.S.doc 30/08/06 8 YA11 16(1) 01/10/06 01/10/06 30/08/06 01/10/06 Fallings Heath House Version 5.2 Page 30 12 YA14 16(1) The home must review and amend the recording systems in place relating to service users activities. Records must demonstrate that service users are offered a range of in house and external activities, on a regular basis – Not met. Requirement originally made November 2005. Full and accurate records must be maintained of all meals taken by service users. The home must implement self medication risk assessments based on each persons individual capabilities – part met. Requirement originally made November 2005. The home must follow its policies and procedures for the storage of medication – Part met. Requirement originally made November 2005. 01/10/06 13 14 YA17 YA20 Schedule 4 13(2) 30/08/06 01/10/06 15 YA20 13(2) Covert medication practices must only take place if records demonstrate the home is complying with relevant legislation and good practice guidance. Staff that administer medication must not sign medication administration records prior to giving service users their medication. The home must review the management of controlled drugs to ensure they comply with relevant legislation and good practice guidance. The home must cease the practice of recording a service 25/08/06 Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 31 16 17 YA21 YA22 12 22 users tobacco intake on medication administration records. Funeral wishes for all service users must be sought, with records maintained on file. A record of all issues and complaints must be maintained in the home, including details of any investigation, action taken and outcome. Complaint records must be checked at least three monthly. The home must review its procedures for service users purchasing aids and adaptations from their personal finances and demonstrate that on service user is discriminated against. 03/12/06 25/08/06 18 YA23 23(n) 01/10/06 19 YA24 23(4) A copy of the reviewed procedures must be forwarded to CSCI. All requirements identified in the 01/10/06 fire departments report must be acted upon, or written evidence supplied to CSCI from the fire department stating that this is no longer the case –Part met. Requirement originally made November 2005. Chipped paintwork must be repaired throughout the building. Worn and damaged garden furniture must be replaced. The sandpit must be cleaned on a regular basis. All light covers in the kitchens must be cleaned. Wheelchairs must not be stored in the sensory rooms. 30/12/06 20 YA24 23 Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 32 All fire doors must close appropriately 21 YA29 23(n) Monitoring systems must be introduced for the use of equipment for the named service user, detailing how, who and when equipment is used. All laundry staff must use personal protective equipment. Food items must not be stored in the laundry. COSHH items that are secondary dispensed must have the correct labelling. Data sheets and risk assessments must be in place for all COSHH products. Personal protective equipment must be available and used for anyone entering the main kitchen. All staff must hold a NVQ level 2 or above, or be working towards achieving this – not met. Requirement originally made November 2005. 25/08/06 22 YA30 16(j) 25/08/06 23 YA32 18(1) 30/12/06 24 YA33 18(1) The home must ensure staff 30/12/06 (including regular agency staff) have training in communication methods relevant to the needs of service users - Part met. Requirement originally made February 2004. The home must ensure that all records in Schedules 2 and 4 of the Care Homes Regulations 2001 are kept in the home for all staff, including regular agency staff -Part met. Requirement originally made July 2002. 30/12/06 25 YA34 Schedules 2,4 Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 33 26 YA35 18(1) The home must ensure all staff; including regular agency staff receive equal opportunities training – Part met. Requirement originally made February 2004. 30/12/06 27 28 YA35 YA36 18(a) 18(2) All staff must use Learning 30/12/06 Disability Award Frame-work accredited training. All staff, including regular agency 30/12/06 staff must have at least 6 supervision sessions a year – Part met. Requirement originally made June 2005. Information gathered from the 30/12/06 service user/family questionnaires must be analysed, with the findings incorporated into the development plan for the home – Part met. Requirement originally made November 2005. A formal quality assurance system must be implemented – Part met. Requirement originally made November 2005. An annual audit of the quality assurance system must take place – Not met. Requirement originally made November 2005. A policy for quality assurance must be implemented. All records required by regulation 01/10/06 must be up to date and accurate. Amended correspondence must 01/10/06 be sent to the families of service users informing them of the correct assessment level made by CSCI. All staff, including regular agency 30/12/06 DS0000033324.V307836.R01.S.doc Version 5.2 Page 34 29 YA39 24 30 31 YA41 YA41 17 17 32 YA42 13(3-6) Fallings Heath House staff must undertaken moving and handling, fire safety, food hygiene, first aid and infection control training - Part met. Requirement originally made September 2003. 33 YA42 13(3-6) All staff that complete risk assessments must undertake training in order to complete this task – Not met. Requirement originally made June 2005. The home must review all of its fire policies and procedure and ensure they are specific to the needs of service users and the numbers of staff on duty during the day and night – Part met. Requirement originally made November 2005. 30/12/06 34 YA42 13(3-6) 01/10/06 35 36 YA42 YA42 13(5) 13,16,23 All staff must be re-trained in the 25/08/06 use of slings, hoists and moving and handling. 01/10/06 All staff must undertake regular fire drills. A wiring certificate for the building must be kept on the premises. Safe working risk assessments must cover all topics as listed in standards 42.2 and 42.3 of the national minimum standards. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fallings Heath House DS0000033324.V307836.R01.S.doc Version 5.2 Page 35 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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