Inspection on 20/11/06 for Fallings Heath House

This inspection was carried out on 20th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 30 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 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 Lesley Webb Unannounced Inspection 20th November 2006 09:30 Fallings Heath House DS0000033324.V320531.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.V320531.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.V320531.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.V320531.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. 15th August 2006. Date of last inspection 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.V320531.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 one service user, interviewing staff, looking at records and observing care practices before giving feedback about the inspection to the service 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. For example the people chosen consisted of both male and female with differing communication needs and from various backgrounds. Prior to the unannounced inspection information relating to the service was sent to the Commission for Social Care Inspection by the home. This was also used when forming judgements regarding service provision. Information supplied includes fees charged which is £935.00 per week. As in the previous inspection the overall findings show that there has been progress in some areas, but major shortfalls remain. Assessment information has improved but care planning is muddled and disjointed and does not provide staff with a clear picture of the service users’ needs and aspirations. The home lacks clear leadership, with evidence contained throughout this report that this is having a detrimental effect on the quality of service provided. The inspector would like to thank service users and staff for their co-operation and assistance during the visit. What the service does well: All care staffs that were spoken to were able to explain what the whistle blowing policy is and how this supports them to report bad practice. Staff also were able to explain how they communicate with people living at the home, however some practices witnessed appear to contradict comments made by staff. There is a lot of documentation that indicates the home attempts to involve service users in decision-making. All files sampled contained consent forms in picture format, the menu has been produced in a colour coded system again to aid decision making and an activity folder has been produced with the inclusion of photographs. The atmosphere within the home is friendly and welcoming, helping to create an inclusive place for people to live. Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home must take action to meet in full requirements that have been identified in previous inspections. Presently there are twenty-six requirements outstanding. These include implementing care plans for the social, emotional, communication and independent living needs of service users, ensuring care plans include specific aims, completing risk assessments based on individual needs and capabilities, improving the recording of activities, improving the storage of confidential information, addressing some maintenance of the home, ensuring all records required by regulation for the employment of staff are in place and improving some aspects of health and safety monitoring. Fifty-two new requirements were identified in this inspection. These include maintaining evidence of outcomes and achievements of specific goals for service users, ensuring staff use appropriate forms of communication when talking to service users, ensuring staff understand their responsibilities in Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 7 relation to confidentiality, reviewing of policies and procedures, auditing of all records maintained in the home, improving some health related records, improving some medication practices, supporting service users to understand their rights to complain, completing further maintenance of the building and improving some infection control practices. Improvements are also required to staffing. Recently staffing levels have deteriorated resulting in the quality of service people living at the home receive being affected. Staffing levels must increase, including improvements to the days and times drivers, laundry, domestic and kitchen staff are allocated, higher numbers of staff must be enrolled to achieve a NVQ qualification, the majority of staff still require person centred planning training and greater numbers of staff require training in infection control, first aid and food hygiene. Further work is also required to improve the quality assurance systems within the home. Many of the audits that form part of this process are not being completed accurately and therefore cannot be relied upon to measure if the home is achieving its aims and objectives. 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.V320531.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.V320531.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to some information about service provision and attempts are made to ensure service users understand services they can receive. Changes in service user needs are monitored through assessment processes. EVIDENCE: Previous requirements relating to the statement of purpose and service user guide are now met. Both documents have been updated to reflect services and facilities provided by the home. Documentation about service provision is displayed at the entrance to the home and given to families and other people who act on behalf of service users due to people living at the home having 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 no new service users are being admitted and therefore Standard 4 is not applicable. Since the last inspection an assessment of needs has been completed for each person living at the home, with copies maintained on file and forwarded to the Commission For Social Care Inspection (CSCI) and contracts of residency have been completed for all service users. Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 10 All staff that were interviewed were able to explain how they communicate with people living at the home. Observations made by the inspector confirmed that staff attempts to communicate with service users by observing behaviours, facial gestures and body language. It was noted that two service users care plans state that simple Makaton be used to aid communication. The inspector did not witness this being used at any time during the inspection. Through assessing the service against the twenty-two priority standards it is possible to confirm that the home is not always able to demonstrate its capacity to meet the needs of the individuals it provides care for. There is evidence that staff do not always have the skills to meet the needs of the service users, staffing levels are not being maintained impacting on activities and other practices and monitoring systems are not being accurately maintained. Evidence supporting this was gained for example, through observation of care practices, discussions with staff, outstanding requirements and examining of training and other records maintained within the home. Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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: As at the previous inspection the inspector sampled 3 service users files and found they all contained plans of care, but that the contents varied in terms of detail, aims and objectives. The inspector recognises that work has been undertaken to include aims and goals in personal development plans (see standard 11) however the home must continue to develop all other care plans accordingly. 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. A previous requirement to arrange for all staff to undertaken Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 12 training in person centred planning remains unmet. The service manager states that up to 7 staff attended training the previous week but no certificates were available in the home to validate this. Until at least two thirds of staff at the home have received training in this area the requirement will remain. When examining service user files the inspector found records that require archiving, as they are no longer relevant and have the potential to confuse staff delivering care. For example one persons file contained a risk assessment dated 2002 that contained conflicting information to a more up to date assessment, another service users file contains old communication guidance that conflicts with other guidance and another service users file contains information relating to day-care facilities that ceased to exist two years ago. In addition to this further work must be undertaken to ensure information is stored in line with the Data Protection Act 1998. For example information relating to personal care a service user receives was found to be displayed on the wall of the office adjacent to the entrance of the home, accessible to visitors and anyone else entering the building (the service manager removed this immediately when brought to her attention). Further work must be undertaken to ensure staff are aware of their responsibilities in this area. The inspector found some 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. Work has been undertaken to address requirements identified in the previous inspection relating to risk assessments for service users. All files sampled contained assessments of risk for areas including toileting, transport, personal care, and the environment. All have been reviewed within agreed timescales and many have now been completed based on each persons individual needs and capabilities, with only minor work now required in this area to meet this requirement in full (for example assessments for managing finances still appear to be generic). Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to some records evidence that some social, educational and recreational activities meet individual’s expectations. Continued improvements to record keeping and improvements to staffing levels will allow service users to lead fulfilling lives. EVIDENCE: Four of the eight requirements identified in the last inspection are now met in full, with the remaining requirements part met. A ramp is now provided ensuring that the homes transport is accessible to everyone, sensory rooms are open from 10am to 6pm every day, arrangements have been made for all service users to have a holiday and records are maintained of meals taken by service users. Progress has been made to introduce specific aims and goals for individuals with a breakdown programme for each task however no evidence of Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 14 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). Programmes viewed include tasks such as tiding of bedroom, preparation of food, preparing toast and dressing. Some improvement has also occurred in relation to the recording systems in place for service users activities. Each service user now has a weekly activity timetable, personal development skill timetables, activity logs and evaluation sheets completed. When examining the new system the inspector found that no external activities are planned for weekends, there is no allocated driver for the homes mini bus of a weekend, activity timetables are not always being adhered to (without any justifiable reason recorded) and staff are either not always following personal development timetables or are not accurately recording if these have occurred. For example one persons timetable states that they should have gone bowling but that they tidied their bedroom instead, without no explanation as to why, another service users records state they like to access the cinema and go swimming but no evidence of this occurring could be found and another service users file contained different tasks that they had undertaken to those recorded on their personal development plan. It was also noted that many service users records state ‘ride on the mini bus’, with the majority of recordings not including a destination. When investigating this the inspector found that there is a lack of drivers at the home, with priority given to arranging a driver for mornings so that some service users can access a daycentre. Other service users are being taken in the mini bus when particular service users are escorted to day-care but that in the main they do not then continue on with the journey to undertake an activity. The inspector questions the value of this as no service users file evidences a preference for this form of activity. Other records (such as staff rotas) and discussions with staff confirm that reduced staffing levels (see standard 33) and the lack of drivers is impacting on activities service users are being offered and participate in. The impact of reduced staffing was also evidenced in the minutes of a community care review document where it is recorded that activities have been reduced and a service users needs are not being met in this area. The inspector recognises that improvements have been made but further work is still required to evidence that service users live fulfilling lives. An activity folder has been introduced that shows pictures and photographs of different activities including bowling, swimming, sensory room, daytrips, cinema, shopping, site seeing, leisure clubs and visits to the pub. In-house Activities include Lego, painting, massage and music. The inspector was informed that this is used to aid communication with service users and to obtain their views on activities they wish to participate in. As mentioned above records do not demonstrate service users participate in a range of external activities and therefore questions the appropriateness of offering activities if not provided. Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 15 Evidence was found that many service users have contact with family members and that the home seeks their views for service users who lack capacity to consent. No relatives were available during the inspection to seek their views on the homes systems for maintaining contact, however no evidence was found of the home being lacking in this area. The home has a written policy for personal and sexual relationships. This requires reviewing to ensure it reflects practices within the home and complies with legislation. Improvements to records of meals taken and menus have been made. Menus now offer a choice of meals and individual records of meals taken are being maintained. The menu is produced in a colour-coded format as an aid to communication for service users. It is recommended that advise be sought from a qualified person in relation to menu choices in order that the home can be satisfied it offers nutritionally balanced choices appropriate to the season. As at the previous inspection the nutritional assessments are in place for everyone, with staff demonstrating some knowledge of their contents. Fallings Heath House DS0000033324.V320531.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. 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. Although medication practices have improved further work is still required to ensure systems are safe. Further work is required to ensure all health needs are monitored and met. Generally privacy and dignity is respected. EVIDENCE: In the main practices observed and discussions with staff confirm service users receive personal care and assistance in a sensitive manner. Staff were seen talking in a respectful yet friendly manner to service users and undertaking personal care in the privacy of their bedrooms. One incident was witnessed that compromised a service users dignity. This was discussed with the service manager who agreed to take action and discuss with staff. All 3 service user files sampled contained evidence that some of their health needs are being monitored appropriately. Records confirm that service users receive intervention from specialists including general practitioners, dentists, opticians and chiropodists. Further improvements are required to ensure all health related records are completed in full. For example some health action Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 17 plans are incomplete and some records state follow up treatment or appointments are required but no evidence of this occurring is recorded. No files sampled contained evidence that service users receiving hearing checks or that male service users undertake testicular screening. The inspector also instructed that a care plan and risk assessment be completed for a particular service user who refuses health screening and intervention. Many of the requirements identified in the previous inspection relating to medication have been met. Covert practices have ceased, staff no longer sign medication administration sheets without witnessing medication being taken, the management of controlled drugs have been reviewed and medication risk assessments have been completed. When assessing if the home is following its policies and procedures for the storage and management of medication the inspector was unable to confirm that they are being adhered to as several policies were found to be in place, some of which contain contradicting information. No staff that were spoken to were able to confirm which policies were current and which require archiving. The confusion regarding policies and information was further reinforced when the inspector found a policy and guidance on the convert administration of medicines to adult in-patients dated 2002 signed by the senior care manager, medication policies for controlled drugs dated 1998 and different policies located on units within the home to those in place in the office. Medication practices were observed and generally found to be adequate. Appropriate records are maintained of medication entering and leaving the home and most medication is stored according to manufacturers instructions. Further work is required to ensure written instructions are maintained pertaining to areas of the body that prescribed creams should be applied, out of date creams are not used, staff sign for all prescribed medication when administered and that medication administration records are not altered. Currently there are fourteen staff authorised to administer medication. Not all have undertaken accredited medication training. An up to date record of staff authorised to administer medication must be implemented along with samples of their signatures and initials. The home has policies for care of the dying and death. Of the 3 service users files sampled all contained evidence that the home has sought the views of families for funeral arrangements but as yet outcomes have not yet been included on file. Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff have knowledge of protecting service users from abuse however policies and guidance relating to protection, aggression and physical interventions are not relevant to the setting and in some instances do not comply with legislation, placing people at risk. Management of service users finances is good. No evidence could be found that the home supports people to understand their rights to complain. EVIDENCE: The inspector could find no evidence that service users are supported to understand their rights to complain. The homes statement of purpose states that there is a complaints video and resident’s rights video that are regularly shown at monthly service user meetings. No evidence of this or service user meetings taking place could be found. 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 but no records or systems are currently in place to demonstrate issues raised on behalf of service users by staff. Since the last inspection records of complaints have improved, meeting two previously identified requirements. Adult protection, violence and physical intervention policies were viewed. All are required to be reviewed as either are out of date, do not comply with relevant legislation or are not relevant to the home. For example the physical intervention policy is dated 2002 and describes practices within a hospital setting and the adult protection guidelines are not the most current Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 19 available. It was pleasing to find that all staff that were spoken to demonstrated understanding of the whistle blowing procedure and protecting service users from abuse and that the majority of staff have received training in adult protection. Work must now be undertaken to ensure all staff receive training in violence and aggression. Records in relation to the management of service users personal finances were examined. Each person has an individual allowance sheet maintained that detail monies in and out of the home. In addition to this receipts are obtained. All monies sampled were correct and reflected records maintained. The inspector was informed that all service users finances are managed by the local authority appointeship unit who have legal responsibility for managing and monitoring service users finances. When examining records in the home the inspector found that each person has a bank account that has been opened by a senior care manager with two senior care managers authorised to withdraw finances. The inspector instructed that written confirmation be supplied to evidence that the appointeeship unit is aware and agrees with this situation due to savings in these accounts having the potential to impact on benefits service users receive. A previous requirement instructing the home to review its procedures for service users purchasing aids and adaptations from their personal finances is now met, with a new policy in place that ensures no service user is discriminated against. Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements to the environment have been made. Further improvements must be made to ensure service users live in a safe, well-maintained and comfortable environment. EVIDENCE: 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. A tour of the building was undertaken, it was pleasing to see that many requirements identified in the previous inspection have now been met. Worn and damaged garden furniture has been removed, light covers in the kitchens have been cleaned, wheelchairs are no longer stored in sensory rooms, Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 21 monitoring systems have been introduced for equipment, food items are no longer stored in the laundry and personal protective equipment is available for anyone entering the main kitchen. Outstanding requirements include repairing any chipped paintwork and maintaining records for the maintenance of the sandpit. When touring the building the inspector found that many fire doors do not close appropriately. The service manager states that work was recently undertaken to address this and did not understand how this situation could have arose again. The kitchen was seen and found to be clean, with staff completing all of the required checks for food safety. The laundry was also viewed. There were no liquid soap, gloves and aprons available in the laundry to reduce the risks of cross infection and there is a lock on the laundry door but the key is left in it and it is easy to access, this could place service users at risk if ingesting hazardous substances. There were no cleaning schedules for the laundry on the day on the inspection and staff require training in infection control to ensure that service users are fully protected against the risk of cross infection. Only two of the four units are now used by service users. Both were examined and generally found to be adequate in terms of furnishings and fitments. Fern unit’s kitchette requires attention. Many of the cupboard doors are broken and the walls, paintwork, flooring and radiator are either stained or dirty. The decorative wallpaper boarders are torn in cherry unit. For both days of inspection an area of flooring was damaged near to the entrance of the home. Staff have attempted to make it safe by covering with a dining table and informed the inspector that they have been assured someone from the maintenance department would visit to assess by the end of the day. No evidence of this occurring could be found. Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 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 receive some training to support the people who use the service, improvements will enhance knowledge and practice. Reduced staffing levels is impacting on the provision of service people receive living at the home. Systems for staff support are good. EVIDENCE: Five staff files were viewed in order to see how much progress the home is making in improving its staff training, supervision and recruitment records. Further work to provide training for staff is required to address three requirements identified in the previous inspection in full. Greater numbers of staff are required to undertake learning disability award framework accredited training, hold or be enrolled on NVQ level 2 or above qualifications and to have undertaken equal opportunities training. Specialist training specific to the needs of people living at the home must also improve. This must include the provision of autism and epilepsy training. Individual training needs assessment and record of training undertaken appear to be in place for all staff Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 23 (in one folder) signed by manager but no evidence of staff involvement in their compilation could be found. Staffing ratios have deteriorated since the last inspection. There are currently eight service users residing at the home, with records and management confirming a minimum of four care staff required to be in place during the morning and afternoon shifts. These levels are not being maintained. In addition to this domestic, laundry and kitchen hours have been reduced with the reduced numbers of care staff having to undertake additional duties in these areas. Evidence throughout this report indicates that the reduced staffing levels are having a detrimental effect on service provision. The inspector raised concerns regarding this situation to the service manager who agreed action should be taken to rectify the situation. Records of staff meetings confirm that regular meetings occur (above the national minimum standard) with minutes maintained. Records of meetings show that staff meetings are very informative. Improvements to the numbers of staff supervision have also taken place with many staff on target to receive a minimum of six sessions this year Of those files seen all of them contained suitable written references, forms of identification, recent photographs and Criminal Record Bureau disclosures were in place. There were no copies of application forms and some files did not contain a job description. It was noted that many staff have been employed at the home prior to July 2004 resulting in no checks made against the protection of vulnerable adults register. It is strongly recommended that this now occurs to ensure service users are suitably protected. When examining records the inspector found that the home allows people from the probation service to undertake community hours within the home. No records apart from a contract between the home and the probation service and individual timetables are currently in place at the home. The inspector instructed that risk assessments and declarations of convictions must be in place along with a written policy regarding this practice to safeguard those living at the home. The senior care manager on duty contacted the probation service immediately requesting the above information that agreed to forward risk assessments but who questioned disclosing convictions. The inspector advised the senior care manager of the relevant legislation regarding people working within a care setting (either paid or voluntary) and the requirements to disclose convictions. The inspector stressed that no one must undertake duties at the home prior to a disclosure being in place. Fallings Heath House DS0000033324.V320531.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41 and 42. 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: The home still does not have a registered manager, with the inspector concerned that the Responsible Individual for the home having not fulfilled their obligations in this area. The inspector contacted the Responsible Individual during the inspection regarding this situation that agreed to take action immediately. Quality assurance monitoring has been introduced. The policy relating to this states that the views of service of service users were gathered during 2005 and printed January 2006 and that an audit of the quality assurance system Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 25 will take place December 2006. Monthly audits are completed for health and safety, medication, fire, activities, menus and supervisions. The inspector questions the accurateness of some of the audits, as the majority do not identify any shortfalls when evidence gathered throughout the inspection contradicts this. This was discussed with the service manager who agreed that staff completing these do not appear to have the required understanding of quality assurance. As mentioned in other parts of this report some of the policies and procedures viewed are inappropriate for the setting or require updating. For example some of the policies referred to hospital settings, the home is not registered to provide nursing care, in other policies the information contained within them was confusing and in some cases did not reflect current good practice or comply with current legislation. Also as mentioned throughout this report many record systems need improving. Without improvements the home cannot be confident that it is meeting service users needs in full and fulfilling its legal obligations. Some safe working practices within the home are adequate but other require improvement. Thirty-one staff currently are employed to work at the home. Records confirm that fourteen of these have undertaken a fire drill. Records are being maintained for monitoring of equipment for a named service user but no evidence of any action taken to address the issues this has identified. A risk assessment is required for the broken flooring located in the main entrance of the home. Maintenance records for the home were spot checked and generally found to be in order. Since the last inspection all staff have been retrained in the use of the hoist and moving and handling, meeting a previous requirement. Progress has also been made to ensure all staff, including regular agency staff undertaken fire safety training. Further action must now take place to ensure all staff receive training in food hygiene, first aid and infection control training and that all staff that complete risk assessments undertake training in order to complete this task. A previous requirement to introduce safe working risk assessments that cover all topics as listed in standards 42.2 and 42.3 of the national minimum standards is part met. The inspector had difficulty assessing progress with this requirement as many documents were found to be duplicated, stored in different folders or alongside other assessments dating from 2002. The fire management folder was viewed and found to contain out of date fire regulations, old fire risk assessments and a new assessment dated February 2006. Upon inspection of the new assessment it was found to be lacking in information relating to the disabilities of people living at the home and the impact of reduced staffing levels. A previous requirement to ensure any COSHH items that are secondary dispensed must have the correct labelling remains not met. The inspector found dishwasher powder in a container with no details apart from ‘dishwasher powder’ recorded on it. The risk assessment for this product states it must be kept in original container. One unidentifiable bottle of solution with no label Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 26 was found and when the senior on duty was asked what it contained stated, “think it might be zoflora, it should be labelled”. The member of staff was instructed to remove this from the premises immediately. Another container with original label for ‘shout’ cleaner was found to contain a different disinfectant. Risk assessments completed by the home in the main do not detail instructions or guidance for the practice of secondary dispending. Fallings Heath House DS0000033324.V320531.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 3 2 3 3 2 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 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 2 13 2 14 2 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 2 1 X 1 1 1 2 X Fallings Heath House DS0000033324.V320531.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 YA3 Regulation 12(1) 15 Requirement Staff must communicate with service users using their preferred modes of communication as detailed in their plans of care. Care plans must cover all aspects of personal, social and health care needs – part met. Requirement originally made November 2005. All care plans must include specific aims or goals – part met. Requirement originally made August 2006. Risk assessments must be completed for all service users based on their individual needs and capabilities -Part met. Requirement originally made November 2005. All service users personal records must be stored in line with the Data Protection Act 1998 – not met. Requirement originally made August 2006. Staff must be made aware and demonstrate understanding of Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 29 Timescale for action 30/11/06 2 YA6 15 31/12/06 3 YA9 13(4) 31/12/06 4 YA10 17 12(1) 31/12/06 their responsibilities in relation to confidentiality. 5 YA11 16(1) The home must implement care 31/12/06 plans for the social, emotional, communication and independent living needs of service users Part met. Requirement originally made November 2005. Evidence of outcomes and achievements for specific goals must be maintained. 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 - part met. Requirement originally made November 2005. If planned activities do not occur records must be maintained detailing why. The policy for personal and sexual relationships requires reviewing. Staff must follow service users care plans in relation to items of clothing and footwear to be used. Health action plans must be completed in full. All service users must have access to hearing tests. All male service users must have access to testicular screening. A record of all treatment and appointments must be maintained. Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 30 6 YA14 16(1) 31/12/06 7 8 YA15 YA18 10(1) 12(1(a) 12(4(b) 15 12(4)(a) 12(1) 13(1) 30/01/07 22/11/06 9 YA19 31/12/06 10 YA19 15 12(1) 13(1) 11 YA20 13(2) A specific care plan and risk assessment must be completed for the named service user who refuses health screening and intervention. The home must follow its policies and procedures for the storage of medication - Part met. Requirement originally made November 2005. Written instructions must be maintained pertaining to areas of the body that creams need to be applied. Out of date creams must not be used. Staff must sign for all medication when administered. Medication administration records must not be altered or tampered with. 30/11/06 30/11/06 12 13 YA20 YA21 14 YA22 An up to date record of staff authorised to administer medication must be implemented with samples of their signatures and initials. 13(2) All staff that administer medication must undertake accredited medication training. 12(1)(2)(3) Funeral wishes for all service users must be sought, with records maintained on file – part met. Requirement originally made August 2006. 22 The home must be able to 4,5 demonstrate it supports service users to understand their rights to complain. The home must fulfil its obligations in relation to showing the complaints and 30/01/07 31/12/06 31/12/06 Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 31 15 YA23 13(6) resident’s rights video as stated in the statement of purpose. The home must review its adult protection, violence and physical intervention policies and procedures. 30/01/07 16 YA23 13(6) 20(3) 17 YA24 23 All staff must undertake training in violence and aggression. Written evidence must be 31/12/06 forwarded to CSCI demonstrating that the appointeeship unit responsible for managing service users finances are aware of and agree with the bank accounts that have been set up by the home and with staff authorised to withdraw monies on service users behalf’s. 14/12/06 Chipped paintwork must be repaired throughout the building – not met. Requirement originally made August 2006. The sandpit must be cleaned on a regular basis – not met. Requirement originally made August 2006. All fire doors must close appropriately – not met. Requirement originally made November 2005. The decorative boarders in cherry unit require replacing. The flooring near to the entrance of the home requires repairing and a risk assessment completed. Fern kitchen requires: All broken cupboard doors repairing. 18 YA24 23 31/12/06 Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 32 Walls and paintwork addressing. All stained areas including the flooring, radiator and bin cleaning. Liquid soap, gloves and aprons must be available in the laundry. The laundry room must be kept secure. A cleaning schedule must be introduced for the laundry. All staff must hold a NVQ level 2 30/01/07 or above, or be working towards achieving this - part met. Requirement originally made November 2005. All staff must receive training in: All staff must undertake person centred planning – not met. Requirement originally made November 2005. Epilepsy. Autism. 21 YA33 18(1)(a) There must be a minimum of 4 care staff on duty during the morning and afternoon shifts when all service users are at home. Care staff must be on duty in sufficient numbers to allow one to one time with service users and for activities to be carried out as detailed in activity planners. Domestic, laundry and kitchen staff must be allocated in sufficient numbers so that these Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 33 19 YA30 16(2)(j) 30/11/06 20 YA32 18(1) 30/11/06 duties do not impact on care received by service users. Drivers must be allocated so that service users can access external activities at a weekend. Drivers must be allocated so that service users can access a range of activities at suitable times. 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. Risk assessments and declaration of convictions must be in place for anyone placed at the home by the probation service. A policy must be introduced for the placing and management of people by the probation service. The home must ensure all staff; including regular agency staff receive equal opportunities training - Part met. Requirement originally made February 2004. All staff must use Learning Disability Award Framework accredited training – part met. Requirement originally made November 2005. The home must be able to evidence staff involvement in the compilation of their individual training and development plans. All staff must receive at least DS0000033324.V320531.R01.S.doc 22 YA34 Schedules 2,4 19(1) 30/11/06 23 YA35 18(1) 30/01/07 24 YA36 18(2) 31/12/06 Page 34 Fallings Heath House Version 5.2 25 YA37 24(a) 26 YA39 24 six supervision sessions per year – part met. Requirement originally made November 2005. That the Responsible Individual include its intentions in relation to management of the home in its improvement plan. 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. 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. That any audits completed by the home are done so accurately. That any shortfalls identified in audits are recorded and included in the annual audit of the quality assurance system. That any staff involved in audits pertaining to quality assurance receive training. That a review of the homes policies and procedures take place with evidence that they comply with relevant legislation and recognised professional standards. DS0000033324.V320531.R01.S.doc 12/12/06 31/12/06 27 YA40 12(1) 17 24 30/01/07 Fallings Heath House Version 5.2 Page 35 That all the homes policies and procedures are relevant to the setting. That policies and procedures are read by and understood by staff. 17 All records required by 30/01/07 Sch 1,2,3,4 regulation must be up to date and accurate – not met. Requirement originally made August 2006. That all service users records are secure, up to date and in good order. That an audit of all records maintained in the home is undertaken and any old or out of date information is archived. All staff, including regular agency staff must undertaken food hygiene, first aid and infection control training - Part met. Requirement originally made September 2003. All staff that complete risk assessments must undertake training in order to complete this task - Not met. Requirement originally made June 2005. 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. 30 YA42 13 (3-6) 23(4) All staff must undertake regular fire drills – part met. Requirement originally made DS0000033324.V320531.R01.S.doc 28 YA41 29 YA42 13(3-6) 30/01/07 30/11/06 Fallings Heath House Version 5.2 Page 36 August 2006. COSHH items that are secondary dispensed must have the correct labelling – not met. Requirement originally made August 2006. The practice of secondary dispensing of COSHH products must be included in the risk assessments. Evidence must be supplied to CSCI of action taken to address the issues identified for monitoring of equipment used by staff for a named service user. A risk assessment must be completed for the broken flooring at the entrance to the home. 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 Refer to Standard YA17 YA22 YA34 Good Practice Recommendations That advice is sought from a qualified professional in relation to menu choices and planning. 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. Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fallings Heath House DS0000033324.V320531.R01.S.doc Version 5.2 Page 38 - 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. 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