Inspection on 17/04/07 for Fallings Heath House

This inspection was carried out on 17th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 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 20/11/06

Fallings Heath House 15/08/06

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 Sue Woods Unannounced Inspection 17th April 2007 09:50 Fallings Heath House DS0000033324.V335427.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.V335427.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.V335427.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 vacant post Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Fallings Heath House DS0000033324.V335427.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 Brief Description of the Service: Fallings Heath is a purpose built, single storey building which is registered with the Commission for Social Care Inspection to provide accommodation and personal care to a maximum of sixteen people who have a learning disability and additional complex needs. At the time of the inspection eight people were living at the home. The Registered provider is Walsall Metropolitan Borough Council. The post of registered manager is currently vacant. The home is located in Darlaston, on the outskirts of Walsall, close to local shops, pubs, a post office and other amenities. The home is divided into three units, however due to a decrease in numbers and the planned reprovision of the service; people are currently accommodated across two units. Each unit provides a 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. People who use the service and their representatives are able to gain information about this home from the Statement of Purpose, Service User Guide and inspection reports produced by Commission for Social Care Inspection. Inspection reports can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk The current fees charged are £964.00 per person per week. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 09.50 a.m. and was carried out by two inspectors over a period of seven hours. The inspection included observation of care experienced by people using the service, talking with staff and managers on duty, looking in detail at all aspects of care for two people with complex needs, observing work practices, examining a number of records to include the homes improvement plan and a tour of the home. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Younger Adults and to review progress made by the home since the last inspection undertaken on 20th November 2006 when thirty requirements were made. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The resource manager was on annual leave when inspectors arrived at the home however later attended to assist with the inspection and to provide support to her management team. All staff, managers and service users present at the home were very helpful and co-operated fully throughout the inspection process. What the service does well: What has improved since the last inspection? Twenty-three of the thirty requirements made at the time of the last inspection have now been met improving overall outcomes for people who use the service. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 6 The four Senior Care Managers employed now have designated responsibilities for example health and safety, medication and activities and discussions held indicated they had a clear understanding of their role and responsibilities. The appointment of a driver has improved the opportunity for people to access and take part in a variety of activities in the community. A Senior Care Manager has recently been allocated responsibility for the development of activities and all activities are recorded. It was reported that all senior staff have attended training on financial regulations since the last inspection. The Improvement Plan submitted to CSCI following the last inspection of the home reflects work being done by the home manager to improve standards and the manager is fully aware of requirements still outstanding. What they could do better: Although staff on duty had a good understanding of the peoples support needs, care plans and risk assessments need to be improved to ensure that both permanent and agency staff are provided with up to date information to meet the individual needs of the people they support and to ensure the health, safety and welfare of service users is fully protected and promoted. In-house activities could be further developed and more appropriate to individuals needs. Systems to control the spread of infection require review to safeguard service users and staff and a policy in relation to adult protection is required to support practice. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Fallings Heath House DS0000033324.V335427.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.V335427.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives are provided with information about what the service offers and the terms and conditions of residency. EVIDENCE: Information about what the service offers is held in the entrance area of the home and produced in a format appropriate to the people accommodated. Terms and conditions of residency were available on the two care files examined. These documents were not reviewed as part of this inspection but the information concerning ‘Choice of Home’ was considered adequate at the previous inspection. Due to the home planning to close at the end of 2007 no new admissions have taken place therefore it was not possible to assess key standard 2 at this inspection. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7, 9 and 10 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Support plans do not provide staff with sufficient and accurate information to satisfactory meet service users individual needs. Service users are supported in decision making processes. People using the service are not fully protected by the risk assessments currently in place potentially placing them at risk. EVIDENCE: All care documentation held on behalf of two service users was examined. Some of the information was found duplicated and files contained conflicting information in relation to individual support needs. For example one care plan examined indicated that the person receives one to one support three hours per morning to assist with personal care but it was reported that this is Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 11 no longer the case. A tool used for recording Nutritional screening was confusing and the information open to error. Although there was evidence that individuals receive an annual review by the placing authority, care plans examined had not been reviewed or updated at the required frequency, which was fully acknowledged by managers at the time of the inspection who stated this task is currently being undertaken. Essential Lifestyle Plans were available for the two people case tracked and were detailed however long-term goals had not been reviewed within the stated timescales. Behaviour support guidelines were seen in place for an individual whose behaviours challenge the service however these had not been reviewed and updated since 2002. STAR charts (Settings, Triggers, Actions and Results) are in place to record behavioural incidents however there was no evidence as to how the information recorded is monitored and evaluated. An incident reporting form had not been completed following a recent incident where the person had hit service users and staff and threw a television, which resulted in the person being administered medication. Due to the complex needs of the individuals and their very limited verbal communication skills, it proves difficult for people to actively partake in decisions about their day-to-day life, their home and the service they receive. However each individual is allocated a key worker and primary care worker to advocate on their behalf and a number of forms have been developed in a pictorial format to aid this process. It was reported that residents meetings have been explored however people do not sit long enough to actively participate. An Advocacy service has previously supported people with a quality assurance exercise but the service is not currently utilised. Assessments to support people with taking responsible risks were available on the files of the two people reviewed however these are in need of further development. For example risk assessments to support community activities were generic in addition to the manual handling assessments for two people who are wheelchair dependent. Discussions held indicated that none of the staff had received training in risk management. A requirement made at the time of the last inspection of the home in relation to all service users personal records being stored in line with data Protection legislation has been met. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for people to develop their social and recreational skills have improved. Family links are maintained, rights and responsibilities promoted and people provided with a varied diet in accordance with their personal preferences. EVIDENCE: Due to the needs of the individuals accommodated it is not possible for people to access opportunities for paid employment. Some people have accessed educational opportunities in the past and two people currently attend a day service throughout the week. Programmes to develop life and independent living skills were available on the files examined and include short and long term goals. A Senior Care Manager has recently been allocated responsibility for the development of activities and all activities are now being recorded. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 13 Throughout the inspection people were supported to access the community and the appointment of a driver has provided greater opportunities for community presence and participation. In-house activities were being provided however the resource manager was advised activities should to be appropriate to individuals needs and that more could be done to engage individuals who were seen to ‘wander’ around the home. A requirement made at the time of the last inspection in relation to improving the quality of recording in relation to activities has been met. Service users are supported to develop and maintain important personal and family relationships and contact numbers and addresses were seen recorded on the files examined. One of the people case tracked regularly attends a youth club, which provides opportunities to meet friends. Staff spoken with stated that positive working relations have been developed between the home and relatives. Discussions held with staff indicate that people are encouraged to develop their self-help skills as much as their ability allows although the majority of people do not have access to the kitchen due to health and safety reasons. Bedrooms are lockable however it was reported that people do not use this facility. During a tour of the home staff were seen to knock on bedroom doors prior to entry and discussions held with them indicate that peoples privacy and dignity is upheld and their rights promoted. The home employs two cooks who provide cooked meals seven days per week. A four-week rolling menu is in place and people are provided with a choice of meals. Menus seen appeared balanced and it was reported that staff have a clear understanding of preferences and the dietary needs of the people accommodated. As previously reported nutritional screening assessments require review. It was reported that none of the service users currently have special dietary requirements however one persons diet is being closely monitored following a recent health check. Preferences in relation to dietary needs, support requirements and any specialist equipment were seen on the two files reviewed. The meal observed over lunchtime was quiet and relaxed and people were given appropriate support. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice and service users are safeguarded by the medication procedures in place. EVIDENCE: Preferred routines and individual support needs were documented however as previously stated manual handling risk assessments need to be individualised. Records seen on the two files examined evidence that people are supported to access NHS healthcare facilities as required and all appointments and outcomes are recorded. Health Action Plans have been developed and information was detailed on the two plans examined. All service users receive quarterly medical reviews with the general practitioner. A corporate medication policy and procedure is in place in addition to a local policy, which requires dating and signing. The senior care manager with designated responsibility for medication explained the homes procedures, which appeared satisfactory at the time of the inspection however at lunchtime Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 15 a service user was observed being administered his medication not as per the prescriber’s directions. Regular medication audits are undertaken so errors can be picked up without delay, investigated and appropriate action taken to protect the service users interests. Records are maintained of incoming and outgoing medication and appropriate storage maintained. A record of staff authorised to administer medication has been implemented along with samples of their signatures and initials, as required by the previous inspection. The Community Pharmacist has recently visited the home to provide advice and support. It was reported positive working relationships have been developed with the pharmacist and other healthcare professionals. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are protected by staff being aware of procedures for managing concerns and complaints and personal finances. However people may be vulnerable if policies relating to abuse and aggression are unavailable or not followed. EVIDENCE: The acting manager stated that there have been no concerns or complaints made against the home since the time of the last inspection. The requirement made at the time of the last inspection of the home was discussed as the manager felt that the video referred to in the Statement of Purpose would not be appropriate to inform service users of their right to complain. Instead the home has used advocacy groups and is seeking input from relatives, friends, supporters and key worker staff to ensure views and concerns of service users are shared. The manager committed to ensure that the Statement of Purpose was changed to reflect this new thinking. There has been one referral to adult protection and the acting manager had all information relating to the incident in a confidential file. The allegation made had been upheld and the staff member has been dismissed. The manager was aware of the multi agency adult protection procedures and a copy of the guidelines was in place however there is no policy to support the process. All staff, with the exception of one, have now attended adult protection training. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 17 The procedure in place for ‘aggression towards staff’ suggests that risk assessments should be completed for potential ‘violence’. The acting manager confirmed that these assessments have not been carried out and evidence within the care files suggest that incidents occur that would warrant such an assessment. Two senior care managers who spoke with the inspectors confirmed that robust financial procedures are in place to safeguard service users. Financial records examined evidence that two signatures are obtained for all transactions. Pictorial financial guidelines were available on the care files examined and signed by the service user in addition to procedures for service users purchasing items of equipment. It was reported that the department audits service users individual saving accounts, which are held at the Civic Centre. The resource manager stated that all senior support staff have attended training on financial regulations since the last inspection. Following the requirement made at the time of the last inspection of the home the manager confirmed that all individual bank accounts have been closed. The requirement thus is removed. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service are provided with a clean and comfortable place to live. EVIDENCE: A full tour of both units was undertaken. Due to the re-provision of the service the eight people currently living at the home are accommodated across two units known as Fern Unit and Cherry Unit. Each unit provides a lounge, dining area and kitchenette. A visitor’s room and quiet/activity room are also available. Service users are provided with single bedrooms, which have been personalised. En-suite facilities are not provided however communal bathrooms are located nearby. A bath panel in Fern unit requires attention and a risk assessment to support the use of free standing heaters seen in communal areas is required . Other requirements made at the time of the last inspection of the home have been met. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 19 Service users have access to large enclosed gardens and contractors are responsible for the maintenance of these. At the time of the inspection lawns were in need of attending to. The resource manager confirmed that all requirements made by the Fire and Environmental Health Department have been met. A domestic member of staff is employed and the home was generally found clean and tidy throughout. However systems to control the spread of infection require review for example liquid soap was not available in all communal bathrooms and toilets and unnamed bathmats in need of replacement were found. A full time laundry assistant is employed by the home to undertake washing and ironing responsibilities. It was reported that clinical waste is disposed of with household waste as per the Council policy. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32,34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are supported by a committed and enthusiastic staff team who work within the resources available to provide effective support. Improved training opportunities and appropriate use of agency staff enable service users needs to be met within the home and within the local community. EVIDENCE: All staff who spoke with the inspector felt well supervised and supported. Lists were seen on the wall in the office identifying supervision responsibilities. Personal training plans were seen in place for all staff. The acting manager confirmed that these have focussed on mandatory training requirements. It was positive to note that permanent agency staff also attend Council run training courses. This was confirmed by an agency worker who has been permanent at the home since August 2006. Two of the four training records seen at random supported that staff have achieved NVQ level 2 in Care. The manager reflected that two staff are currently working towards this award. In addition two senior staff are currently training to be assessors. The manager stated that named staff have also attended training in Epilepsy and Autism. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 21 Cleaning and Laundry staff receive regular supervision and have access to personal protective equipment in order to carry out their roles safely. An agency driver has been used previously by the home and is now booked for two weeks. It was felt by staff who spoke with the inspector that this arrangement has greatly improved opportunities for service users to access the community. Discussions with senior staff supported the improvement plan sent to CSCI following the last inspection of the home that identified that duties have been delegated within the senior team. All staff were clear about their responsibilities and felt that having clearly defined job roles had improved the quality of the service. As the home moves towards closure staff are not being recruited into vacancies when they occur. This means an increased use of agency staff. Where possible the same carers are requested. On the day of the inspection a new agency worker was able to give the inspector information about the care and support needs of a service user being supporting. All staff on duty were enthusiastic, polite and courteous. Staff files were not reviewed as there have been no new staff working at the home since the time of the last inspection. Following a requirement made at the time of the last inspection of the home the acting manger stated that they would no longer be using people placed by the probation service. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39,41 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Resource Manager has a good understanding of the areas in which the service needs to improve. Quality assurance systems require further development to ensure all aspects are performance is reviewed. Record keeping in the home is variable in quality so that service user’s rights and best interests are not clearly safeguarded. The health, safety and welfare of service users and staff is not fully promoted potentially placing people at risk. EVIDENCE: Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 23 Fallings Heath House is currently managed by a resource manager who works part time at the home and part time in another establishment. She is supported by a team of four senior staff who all have delegated responsibilities. Since the last inspection the manager has commenced a full audit against all the National Minimum Standards for Younger Adults and developed an action plan with priorities and target dates. This was discussed during the inspection and the manager was advised to look at alternative quality assurance processes given that she only has 24 hours allocated to oversee the home per week. Pictorial surveys were distributed to service users last year and advocates were used to support people with completing these. The resource manager has not yet had opportunity to gain the views of service users, relatives and stakeholders since the last inspection but committed to undertaking this at her earliest opportunity. Record keeping systems in the home are in need of improvement. A number of records were found undated and not signed. Some essential information had not been reviewed. The manager advised the inspectors that a review of the homes policies and procedures has taken place, and documents outstanding have been identified (e.g. the Abuse Policy) Records evidence that health and safety checks are being performed at the required frequency with the exception of water temperatures. Risk assessments for safe working practices are in place however a risk assessment to support the use of portable heaters needs to be developed. Risk assessments and data sheets for substances hazardous to health are in need of review. There was no evidence that substances are being secondary dispensed as identified at the previous inspection. The range and quality of risk assessments and manual handling assessments for service users require review to safeguard service users and staff (as identified previously within this report). Safe working risk assessments were available in addition to service certificates however the assessment undertaken for electrical hardwiring on 28.09.06 stated that the overall assessment was unsatisfactory. The resource manager confirmed that all requirements made by the Fire and Environmental Health Department have been met. The report from the Environmental Health Officer dated 08.01.07 stated ‘The standard of cleanliness in the kitchen is excellent and a credit to you and your staff’. An issue in relation to the training of staff in relation to the completion of risk assessments was discussed. It was acknowledged that the home had attempted to meet the requirement although it remains outstanding. The absence of a team training matrix for mandatory health and safety training made it difficult to establish which staff had attended training in areas such as Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 24 manual handling, first aid and fire however the manager committed to emailing this information to CSCI by 20/04/07. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X 2 2 X Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 26 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 Requirement Care plans must accurately reflect care and support needs and cover all aspects of personal, social and health care needs – part met. Requirement originally made November 2005.Latest timescale for action was 31/12/06 Risk assessments must be completed for all service users based on their individual needs and capabilities -Part met. Requirement originally made November 2005. Latest timescale for action was 31/12/06 Timescale for action 25/05/07 2 YA9 13(4) 25/05/07 3 YA23 13(6) The home must review its 25/05/07 adult protection, violence and physical intervention policies and procedures and then follow them on all occasions All staff must undertake training in violence and Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 27 aggression. These requirements remain outstanding with the timescale for action being 31/01/07. Liquid soap and appropriate hand drying towels must be available in all areas of the home. Not Met this standard remains outstanding with the previous timescale for action being 30/11/06 Bath mats must be clean and stored appropriately when not in use 5 YA39 24 Information gathered from the 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. Latest timescale for action 31/12/06 20/07/07 4 YA30 16(2)(j) 04/05/07 6 YA41 17 Sch 1,2,3,4 All records required by 11/05/07 regulation must be up to date and accurate – not met. Requirement originally made August 2006. Latest timescale given for action was 30/01/07 All staff that complete risk assessments must undertake training in order to complete this task - Not met. Requirement originally made June 2005. Latest timescale given for action DS0000033324.V335427.R01.S.doc 7 YA42 13(3-6) 25/05/07 Fallings Heath House Version 5.2 Page 28 was 30/01/07 Safe working risk assessments must cover all topics as listed in standards 42.2 and 42.3 of the national minimum standards – part met. Requirement originally made August 2006. Latest timescale given for action was 30/01/07 Regular water temperature checks must be carried out and recorded to demonstrate that checks are made to ensure that hot water does not exceed the maximum safe temperature. COSHH data sheets and risk assessments must be reviewed to ensure they are up to date and accurate. Action must be taken to address issues identified in the assessment for the electrical hardwiring of the home. 8 YA9 13 (5) 9 YA20 13 (2) 10 YA24 23 (2) (b) Manual Handling risk assessments must be carried out to support service users who require assistance with mobility. Medication must be administered as directed by the prescriber on all occasions. The bath panel on Fern Unit must be repaired or replace to make it safe. DS0000033324.V335427.R01.S.doc 04/05/07 04/05/07 11/05/07 Fallings Heath House Version 5.2 Page 29 11 YA6 13 (6) The free standing electric heathers must only be used in conjunction with an appropriate risk assessment Behavioural support 04/05/07 guidelines must be up to date and reviewed to ensure safe support can be offered to service users. 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. 3. 4 Refer to Standard YA22 YA34 YA40 YA12 Good Practice Recommendations That a system be introduced that records/supports staff to raise issues on behalf of service users. That all staff employed at the home prior to July 2004 now undertakes a POVA check. Policies and procedures should be signed and dated to demonstrate that they have been implemented and reviewed. Activities should be reviewed to ensure they are age appropriate. Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fallings Heath House DS0000033324.V335427.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!