Inspection on 03/06/05 for Fallings Heath House

This inspection was carried out on 3rd June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fallings Heath House 14/04/08

Fallings Heath House 17/04/07

Fallings Heath House 20/11/06

Fallings Heath House 15/08/06

Fallings Heath House 23/11/05

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 Walsall Road Darlaston West Midlands WS10 9SH Lead Inspector Lesley Webb Unannounced 3 June 2005 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 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 Stationary 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 E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fallings Heath House Address Walsall Road Darlaston West Midlands. WS10 9SH 0121 568 6297 0121 526 7023 Telephone number Fax number Email 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 MBC Mrs Sharon Dudley Care Home 16 Category(ies) of Learning Disability (16) registration, with number of places Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: A report from the Fire Authority must be received by the CSCI stating that the additional bedrooms comply with Fire Safety Regulations. That the additional bedrooms are used for the service users (whose names have been provided to the CSCI) only. Once the named service users have moved under the reprovision process the home shall revert back to its original registration numbers. Date of last inspection 22nd November 2004 Brief Description of the Service: Fallings Heath is a purpose built, single storey building which provides accommodation and personal care for thirteen persons who have a learning disability with additional complex needs. it is owned by Walsall Metropolitian Borough Council. The home is located in Darlaston, on the outskirts of Walsall, colsoe 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 from autumn/winter 2005. Services will then be provided to existing service users through re-provision of services currently being undertaken by Walsall Metropolitian Borough Council. Due to this the home is not admitting any new service users. Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at the home at 9.00am and stayed until 3.00pm. Due to the needs of the people living at the home the inspector was unable to interview people therefore additional time was spent interviewing staff and observing practices. In addition to this the inspector looked round the building (not including bedrooms) and looked at paperwork to confirm subjects discussed with staff. The registered manager was on leave at the time of the inspection, with the home represented by a senior care manager and the service manager. By the end of the visit the inspector was satisfied that the majority of service users needs are being met by the home and congratulated everyone for their dedication and commitment. The inspector would like to thank service users and staff for their assistance and co-operation during the time spent at the home where she was made to feel very welcome. What the service does well: What has improved since the last inspection? Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 6 Although staffing levels have improved since the last inspection further work must be done to ensure a quality service is provided to all. This opinion was confirmed by staff whose comments included, “ staffing levels and changes with staff are difficult for the service users, it can effect their behaviour” and “staffing ratios effect everything, some clients need more support and staffing levels can restrict choices in activities”. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 4. The homes statement of purpose and service user give give adequate information in order that people can made decisions about services provided by the home. EVIDENCE: An up to date Statement of Purpose along with other information about the home is displayed at the entrance to the home. Information is given to families and other people who act on behalf of service users due to people living at the home having severe communication difficulties. In addition to this there is an abundance of information in picture and large print format in order that information is accessible to people who live at the home. Due to the home planning to close at the end of 2005 no new service users are being admitted and therefore Standards 2, 3 and 4 are not applicable. Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 7. There is a clear and consistant care planning system in place that provies staff with the information they need to satisfactorily meet service users needs. EVIDENCE: Four members of staff were interviewed and were able to give examples of aims/goals contained within service user care plans. These included hygiene, behaviour management and communication. The inspector verified these examples as accurate when checking the relevant care plans all of which were found to be very well organised and up to date. When asked how service users are supported to be involved in the compilation and reviewing of their plans of care all staff stated that due to their capabilities they are unable to actively participate therefore families are involved on their behalf. When asking staff how service users are consulted and involved in making decisions about their lives all staff recognised that this could be difficult due to the complex communication difficulties of the people living at the home but were still able to demonstrate how they attempt to involve them in decision making. For example one person stated, “ it can be basic things like showing Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 10 two or three sets of clothes to see if someone has a preference and giving more than one choice at mealtimes”. Another person stated, “ body language and facial gestures are seen as indicators that someone is making a decision. It is the staff’s responsibility to look for recognition or approval and give wide selections. Everything must always be recorded so that other staff can carry choices forward”. Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15 and 17. Positive efforts are made to support services users to undertake activities and maintain family links. Meals in the home are good, offering both choice and variety. EVIDENCE: Staff informed the inspector that service users participate in activities according to their capabilities. Examples included swimming, bowling, meals out, daytrips and discos. In-house activities include painting, sensory stimulations such as music relaxation and scalp massages. Activities are recorded in individual diaries. They also stated that service users are supported to maintain family contacts via visits, letters and telephone calls. All staff interviewed stated that service users receive healthy food, with comments such as “there is always a choice, we give balanced meals and always include fruit and salad choices every day” and “we try to give healthy options such as puddings without sugar” received. Staff gave examples of service users with specific dietary requirements but were unsure if nutrional assessments had been completed. When checking these comments the Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 12 inspector found that screening and weight monitoring was in place for some service users but not all. Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19. The staff have a very good understanding of the service users personal, physical and emotional needs. Support is offered in such a way as to promote and protect service users privacy, dignaty and independence. EVIDENCE: Staff demonstrated in-depth knowledge and understanding of service users physical and emotional needs and their responsibilities to ensure these are met. For example one person stated, “It’s our responsibility to monitor their well-being and to be aware of their needs. When assisting with bathing we only help with the things they cannot do for themselves, it might be a little thing to us but it can mean a lot to them”. Another person stated, “ due to communication difficulties it is important we read careplans, look at history and communicate with other staff to make sure we are providing support in the right way. It is important we give people choices, talk to them and treat them as equals”. All files sampled by the inspector were very well organised and up to date. Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home has a satisfactory complaints procedure, with staff demonstrating awareness of their responsiblities in relation to the protection of vulnerable adults. EVIDENCE: All staff interviewed demonstrated knowledge and understanding of their roles in relation to supporting service users to complain and in protecting them from abuse. For example one person stated, “ no one that lives here is capable of stating they want to complain, they are very vulnerable so it is our responsibility to monitor changes in behaviour, look for signs, talk to other staff and report any concerns to management”. Another member of staff stated, “if I saw anything I was concerned about I would report it, if nothing was done I would go higher, I would not hesitate”. The inspector was informed that not all staff have undertaken abuse training. Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24. The decoration and furnishings within the home create a pleasing and pleasant environment to live in. EVIDENCE: On the day of inspection the home was clean and free from offensive odours. Although the home is planning to close the inspector could find no evidence that the standard of furnishings and maintenance diminishing, for which everyone should be congratulated. A health and safety tour of the building was undertaken with no issues identified. Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36. Improvements must be made in relation to staffing ratios and training to ensure there is a good match of well qualified staff, in sufficient numbers to offer consistancy of care within the home. EVIDENCE: No progress has been made ton ensure all staff have training in communication methods relevant to the needs of the people living at the home. The inspector was informed that this had been arranged to take place earlier in the year but had been cancelled and rearranged for July 2005. The inspector hopes this will not be cancelled again as the majority of people who live at Fallings Heath have communication difficulties and staff therefore should be given the full support and knowledge in order to be able to communicate effectively with individuals. Staff meetings are arranged every month and even though some of these have been cancelled the inspector found that the numbers undertaken are still above the National Minimum Standards. When viewing the minutes of these meetings the inspector could find no evidence that issues discussed had been actioned and instructed that documentation should be put into place to evidence this. Some improvement has been made to ensure sufficient numbers of staff are employed on each shift, however records indicated that levels are still not Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 17 being maintained to agreed levels due to vacancies and sick leave. The inspector was informed that a recruitment drive is planned in order to address this. Although the inspector found some improvement in relation to the retention of staff documentation relating to their recruitment and selection no file sampled contained all the required information as listed in Schedules 4 and 6 of the Care Homes Regulations 2001. The inspector also instructed that agency staffs CRB disclosure documentation should also confirm when the disclosure was issued and if a POVA disclosure had been issued. Staff that were interviewed all stated that they had attended various courses throughout the year, however records seen by the inspector did not validate these comments no evidence could be found that staff had undertaken equal opportunities training. Training records were not organised and up to date resulting in the inspector being unable to assess that staff had the right skills and knowledge to fully met the needs of the people living at the home. The inspector was shown a training and development format that is being introduced at the home that had been completed for three people, which will hopefully address the collation of training information. It is recommended that this document be stored with supervision and appraisal documentation in order to demonstrate a systematic cycle of action, monitoring and reviewing. Staff that were interviewed confirmed that they receive formal supervision, however amounts varied from three to one a year. Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42. Further work must be completed in order that staff have the appropriate training to promote the health, safety and welfare of services users. EVIDENCE: It was difficult to assess if staff hold up to date certificates in fire, first aid, moving and handling, food hygiene and infection control due to the recording systems presently in place (see Standard 33), therefore these Requirements remain outstanding. The registered manager and senior care managers are responsible for completing risk assessments within the home. No evidence could be found that they have undertaken training in this area. Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 N/A N/A N/A x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x x 3 3 3 x 2 Standard No 31 32 33 34 35 36 Score x x 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fallings Heath House Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 20 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. 2. 3. Standard YA17 YA23 YA33 Regulation 16(2) 10(1) 18(1) Requirement All service users must have nutrional assessments completed and be weighed regularly All staff must undertake abuse training The home must ensure staff (including regular agency staff) have training in communication methods relevant to the needs of service users (REQUIREMENT ORIGINALLY MADE FEBRUARY 2004) There must be a minimum of seven care staff on duty during waking hours when all service users are in the home The home must ensure that all records in Schedules 4 and 6 of the Care Homes Regulations 2001 are kept in the home for all staff, including regular agency staff (REQUIREMENT ORIGINALLY MADE JULY 2002) There must be a dedicated training budget for the home (REQUIREMENT ORIGINALLY MADE JULY 2002) The home must ensure all staff, including regular agency staff receive equal opportunities training (REQUIREMENT Timescale for action 31/08/05 31/08/05 31/08/05 4. YA33 18(1) 31/08/05 5. YA34 Schedules 4,6 31/08/05 6. YA35 18(1) 31/08/05 7. YA35 18(1) 31/08/05 Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 21 8. YA35 18(1) 9. YA35 18(1) 10. YA36 18(2) 11. 12. YA36 YA42 18(2) 13(3-6) 13. YA42 13(3-6) ORIGINALLY MADE FEBRUARY 2004) The home must ensure all staff, including regular agency staff have an individual training and development assessment(REQUIREMENT ORIGINALLY MADE FEBRUARY 2004) An impact assessment of all staff development must be undertaken to identify the benefits for service users and to inform future planning (REQUIREMENT ORIGINALLY MADE FEBRUARY 2004) Issues discussed in staff meetings should have evidence of action taken, by whom and date completed all staff, including regular agency staff must have at least six supervision sessions a year All staff, including regular agency staff must undertake moving and handling, fire safety, food hygiene, first aid and infection control training (REQUIREMENT ORIGINALLY MADE SEPTEMBER 2003) All staff who complete risk assessments must undertake training to complete this task 31/08/05 31/08/05 31/08/05 31/08/05 31/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA7 Y21 Good Practice Recommendations It is recommended that the home implement service user meetings as a tool to involve them in decision making processes It is recommended that letters requesting service users families to comment on funeral arrangements be re-issued E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 22 Fallings Heath House 3. YA35 It is recommended that staff training and development assessments be maintained with their supervision and appraisal records Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 23 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fallings Heath House E55 S33324 Fallings Heath V230502 020605.Stage 4 doc.doc Version 1.30 Page 24 - 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!