Inspection on 13/06/06 for 29 Greenhill Road (westholme)

This inspection was carried out on 13th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 32 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

29 Greenhill Road (westholme) 27/10/08

29 Greenhill Road (westholme) 30/10/07

29 Greenhill Road (westholme) 06/12/06

29 Greenhill Road (westholme) 27/10/05

29 Greenhill Road (westholme) 13/06/05

29 Greenhill Road (westholme) 24/02/05

29 Greenhill Road (westholme) 29/12/03

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Greenhill Road, 29, (westholme) Moseley Birmingham West Midlands B14 9SS Lead Inspector Kerry Coulter Key Unannounced Inspection 13th June 2006 09:25 Greenhill Road, 29, (westholme) DS0000016713.V297391.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 Greenhill Road, 29, (westholme) DS0000016713.V297391.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. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenhill Road, 29, (westholme) Address Moseley Birmingham West Midlands B14 9SS 0121 449 6383 0121 449 6573 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) TRACS Vacant Care Home 14 Category(ies) of Learning disability (14), Physical disability (14) registration, with number of places Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years 14 people requiring care for reasons of learning disability or acquired brain injury (14 LD,PD) Date of last inspection 27th October 2005 Brief Description of the Service: 29 Greenhill Road comprises of two units, TRACS Westholme, and TRACS Hilltop. TRACS Westholme is registered to accommodate ten people under the age of 65, who have a Learning Disability or Acquired Brain injury. Three of the rooms within the accommodation on the ground floor have been adapted to support people with impaired mobility. The remaining bedrooms are on the first floor, and full mobility is required to access these rooms. This part of the home has a communal lounge, dining room, smoke room, kitchen, and bathrooms and toilets on both floors. TRACS Hilltop occupies the second floor of the home. Hilltop provides care and support for four service users working towards more independent living, offering people the opportunity to develop skills such as budgeting, cooking, home making, and taking greater responsibility for planning their lifestyle. This area of the home has a separate staff team, and its own facilities such as a lounge, kitchen, laundry and bathroom. The home has a large, mature garden at the rear. The home has transport, and is located close to local bus routes. The current scale of charges for living at the home ranges from £947.87 to £1494.85. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the field work visit taking place a range of information was gathered to include notifications received from the home, reports from the provider and a pre inspection questionnaire. The unannounced fieldwork visit was carried out over seven and a half hours. This was the homes first key inspection for the inspection year 2006 to 2007. The inspectors spoke with staff, several service users and time was spent observing care practices, interactions and support from staff. Comment cards were received from five service users about their opinions of the home. A tour of the premises took place. Care, staff and health and safety records were looked at. The inspectors extend their thanks to everyone who helped with this inspection. What the service does well: What has improved since the last inspection? This home has improved in many areas. At the last inspection there were many standards where there were major shortfalls, this has now been reduced to five standards. This has had a positive effect on the outcomes for people living at the home. There is a new acting manager who shows commitment to making improvements to the home. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 6 The statement of purpose and service user guide have been updated, these now provide prospective service users with the information they need before making a decision to move in. Notifications received from the home, discussions with staff and sampling of records indicate that incidents of challenging behaviour have now reduced following one service user moving out of the home. TRACS has undertaken a large amount of building and re-decoration work and has plans to do more. This has made the home look much better and a nicer place for service users to live. Odour management has improved so that it is a pleasant place for service users to live. A driver, laundry assistant and cook have been recruited to the home so that care staff can spend their time supporting service users. 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. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 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 the following standard(s): 1, 2, 4, 5 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. TRACS undertakes pre-admission assessments and offers trial visits, but better use of the trial visit is needed to ensure prospective service users needs could be met by the home, and that service users will be able to live safely together. TRACS issues a robust contract. These had not been signed by TRACS or the service user, therefore it could not be established service users are aware of the terms and conditions of their placement. EVIDENCE: Previous requirements were made for the homes statement of purpose and service user guide to be developed to ensure they provided service users with all the information they needed to know about the home. The Manager said that these documents had just been completed and were at Tracs head office and would be available in the home soon. Following the visit copies of the documents were forwarded to the CSCI. These are comprehensive documents. Information recorded in the documents indicates that an audiotape version is available to make the information more easily available to some service users. Of the five comment cards received from service users three said they had received enough information about the home prior to moving in, two said they had not. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 9 The work undertaken with one service user prior to admission to the home was tracked. An assessment had been undertaken and a trial visit made to the home prior to the service user moving in. Likes, dislikes and needs had been identified in the assessment. Where staff had indicated they had not enough information regarding a potential risk, evidence was available that the social worker had been approached for more information on this matter. A report of the trial visit had been compiled, however this was quite brief. It did not record how the prospective service user had interacted with existing service users and gave only limited information regarding an incident of concern regarding their interactions with a member of staff. It was not evident that this incident had been considered as part of the assessment process. Service users files sampled all contained a written contract, detailing the terms and conditions of their stay, and the costs. One document had not been signed by either the Manager or the service user. Greenhill Road, 29, (westholme) DS0000016713.V297391.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Care documents and risk assessments are not available for all service users to fully or accurately underpin service users needs or the risks they face. Service users are consulted on how they wish care and support to be provided. EVIDENCE: Four service users were case tracked either in full or part. For one service user a plan of care was not available. This individual had a wide range of needs to include epilepsy and mental health. An entry in their file dated January 2005 recorded that the care plan was being re-written. April 2005 recorded that the care plan had been typed and May 2005 that it was ready to proof read. However this plan of care was not available in the home. A full care plan must be available that sets out in detail the care required to be carried out by staff to ensure all aspects of the health, personal and social care needs of service users are being met. The three other sampled care plans were seen to be quite personalised and generally up to date. For one individual the care plan was not adequate regarding issues of diversity. It recorded that the individual was not religious but then stated they had no cultural needs. The cultural backgrounds Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 11 of all service users must be respected and information regarding this provided in the care plan to ensure they are supported by staff in an appropriate manner. Three of the comment cards received from service users recorded that they could always make decisions on what they wanted to do each day. The remaining comment cards recorded they were usually able to make decisions. Service user meetings do take place. Minutes of the meetings show that topics of discussion include activities, holidays, their experiences of the home and if they have any complaints. Some risk assessments for service users accommodated on Westholme had not been reviewed recently. Some care documents had identified significant risks, yet no control measures or plans to reduce these were in place. The risk of one service user inappropriately touching females had been identified but there was not an assessment of the risks to female service users. The storage of records has improved and information about service users is generally stored in a manner that respects their confidentiality. However information about one service users wheelchair was seen to be wrongly files in another service users file. Staff practice generally respected service users rights to confidentiality but one member of staff reported to the Manager about the behaviour of one service user. This information was quite personal and was relayed whilst another service user was in the room. However the Manager was overheard to later speak with the staff member, explaining this was not good practice and did not respect the rights of the individual. Greenhill Road, 29, (westholme) DS0000016713.V297391.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Service users generally experience a good lifestyle that meets their individual needs and aspirations. EVIDENCE: The opportunities for service users to undertake interesting and varied activities in the community and at home were tracked. Daily records and discussion with service users indicates that the variety and frequency of activities on offer were adequate. One service user commented that he was happy with the activities on offer and spoke excitedly about his planned holiday to Spain. One Social Worker spoken with before the visit took place commented that the activities offered to the service user she had placed there were generally good. Discussion with staff indicates that issues of diversity are taken into account when planning activities, they gave an example of taking one service user to a pub that met their cultural background. Records also showed that it was planned as part of the activity schedule that staff would sit with one service user reading the Bible. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 13 For one service user regular walks form part of their activity schedule, but the records showed that often these walks took place in the garden rather than the local community. Walks in the garden may not be that fulfilling for the service user and could be quite boring. The home has a good system of shift planning and each service user has a detailed activity schedule that links to their care plan. However the home does not seem to have an auditing system in place to monitor that the activity took place, and if it didn’t happen, why. One service user had been assisted by staff to join a preparation for employment group, however he later changed his mind and instead chose music and computing as activities he wanted to do. One member of staff was observed playing dominoes with two service users. There was pleasant interaction and the service users were enjoying the game. The rights of service users were respected by staff. For example service users were given choices throughout the day, this included what time to get up, what they wanted to eat and if they wanted to go out. Staff were observed to knock on bedroom and bathroom doors before entering. There was evidence in care notes and when talking with service users that family contact is maintained. This can be in person, by letter and phone. Service users have opportunities to participate in food preparation tasks, one service user was observed to be supported by staff to make toast for breakfast. In Hilltop service users shop individually for their own food and have kitchenette type facilities in their bedroom in addition to the main kitchen. Discussion with service users and staff show that the cultural needs of individuals are taken into account when planning menus. The lunchtime meal was of good quality, lots of condiments were available on the table to accompany the meal. Individuals were consulted on what they wanted and staff picked up on the non-verbal cues from one individual that he wanted more food. It is recommended that the system for recording food provided are reviewed. Staff have two separate places to record this- a book in the kitchen and in the service user daily records. Both of these are not being consistently used. One set of records if consistently used would provide a more effective method for recording food provided and enable staff to determine if a healthy and balanced diet was being provided. Greenhill Road, 29, (westholme) DS0000016713.V297391.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care was delivered to a good standard. The quality of plans to underpin this varied, and were not always adequate to ensure needs are consistently met in the way service users prefer or require. The systems for the administration of medication require minor improvement to ensure service users medication needs are safely met. EVIDENCE: Service users were observed to have had their personal care needs met. One service user spoken with said she was supported by staff to go to the hairdressers to have her hair done. One service user wanted to go out into the community in his slippers, staff gently persuaded them that their shoes might be more appropriate. A recent complaint was made regarding one service user wearing ill fitting clothes that did not belong to him. This was fully investigated by Tracs who have taken action to reduce the risk of this occurring again. Discussion with the laundry assistant indicates that systems are in place to ensure clothing does not get mixed up and is returned to the rightful owner following laundering. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 15 Service users who are at risk of self-neglect, and who may choose not to get up, or to undertake personal care were tracked. Clear guidance on how to support the person were not available. Although written care plans were not available for one service user the daily records and discussions with staff did show that staff are trying to spend time with him offering food, medication and personal care. Personal care matrix are in place for service users, staff record on these when personal care has been given. Some of these sampled had not been completed consistently. One service user had a continence chart, this had not been consistently recorded by staff and contained some blank entries. Staff need to complete these consistently to ensure the information they provide is accurate and service user needs are consistently met. Sampled care records show that service users are supported to access regular health checks to include the dentist, optician, chiropodist and GP. It was of concern that for one individual the Chiropodist had identified an infection but a GP appointment did not occur until two weeks later. Health monitoring records did in general detail the outcome of appointments but could be improved. For example, one service user attended the GP surgery for a blood test, the record did not show what the blood test was for and what the outcome was. The Manager was unsure what the test was for and agreed to chase this up. One service user had a risk assessment for epilepsy dated November 2005, it had not been reviewed although it recorded that one was due three months after this date. The epilepsy records for another service user were tracked as the quality of the records had been part of a complaint made about the home. The risk assessment was detailed and had been reviewed in April 2006. A record of seizures had been maintained. Staff do regular observations of this individual when he is in his bedroom in case he has had a seizure. It is recommended that where the record is blank staff record he was not in his room as a blank space could be because staff forgot to complete the record. The CSCI had received two notifications that one service user had a fall. The home has arranged for this individual to have a Physiotherapist assessment regarding the risk of falls. Records show the risk as being low but the home is still to receive a full report from the Physiotherapist regarding this. To further reduce the risk of falls the service user has changed bedrooms where there are fewer stairs to negotiate. Discussion with the service user indicates he was happy to change and is pleased with his new room. Medication management at Westholme was of concern at the last inspection. The system has improved and most of the previous requirements made have been met. It was good that there is a lot of information available for staff about the medication prescribed to service users. Copies of prescriptions are retained so that staff can check the correct medication has been received from the chemist. Audits of ‘as required’ medication are completed to ensure stocks tally with medication records. Some medication administration records Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 16 contained gaps. Staff must sign the record or use the appropriate code if administration is not possible to ensure it is clear that service users have had the medication they need. The medicine fridge temperature had not been taken regularly. This needs to be done daily to make sure medication is stored at a safe temperature. The temperature in the medication room was quite hot, 25°C even though the fan was on in this room. This needs to be monitored to ensure the room is maintained at a safe temperature for the storage of medication and at a comfortable working temperature for staff. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure which ensures service users views are listened to and acted upon. Adult protection systems need to improve to ensure service users are being protected from abuse and their welfare promoted. EVIDENCE: The CSCI received a complaint about the home in March 2006, this related to personal care issues regarding a service users clothing and records regarding epilepsy and monitoring of their well being. The complaint was passed back to Tracs to investigate who upheld one element of the complaint and partially upheld the other two elements. Information provided by Tracs indicates that the complaint was robustly investigated. In March 2006 a service user made a complaint about how he was treated by a member of staff. It was agreed by the Social Worker and CSCI that Tracs would investigate this issue. This has still to be concluded, the Area Director anticipated it would be done by the end of June. The homes complaint log was observed. This detailed complaints received by the home and action taken to investigate and resolve them. Discussion with staff and observation of records indicates that complaints are appropriately responded to. All of the comment cards received from service users recorded that they knew who to speak to if they were unhappy. Four of the five received said that they were aware of the complaints procedure. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 18 It was of concern that records showed that one service user was often verbally abusive to both staff and service users but there was no available care plan or behaviour management plan in place to guide staff as to how to reduce this happening and protect service users. As stated earlier in this report one service user has the potential behaviour of inappropriately touching females. It was not evident that this had been adequately assessed and guidelines put in place to protect female service users. Adult Protection training is provided on a cyclical basis. This training is done via a video and booklet. The Manager said that for senior staff the duration of the training is half a day but is one hour for support staff. A period of one hour is a very short time to cover the important topic of adult protection and prevention of abuse. Tracs must review this training to ensure it is adequate for staff and enables them to recognise potential abuse and respond appropriately to protect service users. The financial records of four service users were tracked. Monies balanced with the record and receipts were available for expenditures. It is good that staff check the monies twice daily to ensure they are correct. For one service user their cheque book had three stubs that were not dated and did not detail the expenditure. Bank statements were not available to track these cheques. The Manager must ensure that bank statements are available and cheque stubs appropriately completed so that service users monies can be properly audited and safeguarded. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Work to improve the structure and fabric of the premises has been undertaken with further work planned to make the home a nicer place to live. EVIDENCE: A tour of both Hilltop and Westholme was undertaken. Not all service user bedrooms were observed as some individuals did not wish their rooms to be seen. Bedrooms observed were generally personalised and were clean. Discussion with the Manager and observation of bedrooms indicate that service users are supported by staff to have a bedroom that reflects their gender, age and culture. The home benefits from having a room for the use of smokers. This room has recently been repainted, one service user commented that it looked nicer than before. The room did have a very strong smell of cigarette smell but the Manager said that a quotation for a new and larger extractor fan had been obtained and she hoped this would be fitted soon. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 20 The main kitchen in Westholme is very spacious but retains a domestic feel. New work surfaces and kitchen cupboard doors have been fitted since the last inspection. Work needs to be done to reseal the worktop by the sink to ensure effective infection control. Lighting throughout the home was generally satisfactory but in one bathroom was very dim and requires a brighter light. Tracs have been undertaking extensive development work of the premises in the last year. Most of the work is completed but refurbishment of some bathrooms still has to be done due to their worn appearance. New carpeting is also to be fitted in hallways and on stairs as the current carpets are quite worn. The Tracs Area Director said that the installation of a passenger lift is under consideration for the benefit of service users who have increasing mobility needs. Comment cards received from service users indicates that they feel the home is usually fresh and clean. Three service users spoken with said that they were happy with their bedrooms. Poor odour control was identified as a concern at the last inspection. Improvements have taken place and a new odour control system has been installed making the home a more pleasant place to live. As required previously pull cords in bathrooms have been replaced due them being grubby. Some extractor fans were observed to be clogged with dirt making them ineffective when used. Some of these are positioned in areas that are difficult to reach by staff. The Manager said that she would request the maintenance person to clean these difficult to reach fans. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in the staffing arrangements have been made but this needs to continue to ensure that service users are supported by satisfactory numbers of appropriately trained staff to meet their needs. EVIDENCE: Positive interactions were observed between staff and service users. One service user commented that ‘staff do a good job considering how many of us they need to look after.’ The pre inspection questionnaire completed by the Manager records that 39 of staff have completed an NVQ in care. This does not meet the standard of 50 but a further 8 staff are currently working towards achieving an NVQ. The last inspection raised concerns regarding insufficient numbers of staff on duty to safely meet all the needs of service users. Staff undertook a full range of multi-role tasks including laundry and cooking and most staff work long days, which results in them each taking a one-hour break during the day. Following the inspection Tracs took action to try and address the issue. A driver, laundry assistant and cook were recruited to the home. Discussion with the Manager indicates that the cook also undertakes some care tasks in the afternoons when the cooking responsibilities have finished. Whilst the staffing Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 22 situation is much improved further review is needed of the numbers of staff on duty when the cook is off duty to ensure there are still adequate numbers of staff to undertake both care and cooking duties. The recruitment records for two members of staff were sampled. For both members of staff there was evidence that references and CRB checks had been received or applied for, checks had also been made against the Protection of Vulnerable Adults Register. One record showed that a member of staff had been dismissed from a previous job. The Manager said that this had been explored by Tracs but the record of this was not available in the file. This information needs to be available for inspection to evidence that a robust recruitment procedure has been followed to ensure service users are protected. The home has a training matrix in place however from this record it is difficult to make a full assessment of the training completed by staff. It did not record all the required topics and showed that not all staff had done training in manual handling, health and safety and medication. Some staff had not done fire training in the last six months. The majority of staff have done first aid and Studio III. However the training plan for the home records that the duration of first aid training is only one hour. First aid is an important topic and it is doubtful that staff could be provided with all the information they need in such a short period of time, therefore this needs review. As detailed earlier in this report it is not evident that the level of training in adult protection is satisfactory due to its short duration. All staff must receive the required training to enable them to meet service users individual and collective needs. Staff meetings are held on a regular basis, it is good that a strategy day has recently been held where staff have been able to contribute towards improvement plans for the home. Supervision records for three staff were sampled, these showed that the quality of supervisions is good but that the frequency needs to improve to ensure the standard of six per year is met and to ensure staff are well supported in their job role. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. The management arrangements of the home have improved and resulted in more positive outcomes for service users but issues of health and safety need to be addressed to ensure service users safety. EVIDENCE: At the last inspection the home was operating with an acting manager and the structure and stability of the management team urgently required review. A new manager has now been recruited who has previous management experience and is nurse trained in learning disabilities. The Manager said that she has recently enrolled on the Registered Manager Award to ensure she gains the right qualifications for the role of the Registered Manager. An application needs to be made to the CSCI for registration. Discussion with two members of staff indicate that they feel the running of the home is improving now that the new manager is in place. One commented that the Manager has a good overview of the home and has given functional roles to individual staff. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 24 One staff member said that the Manager is improving things and that life is better for service users. Systems are in place to assure quality. This includes monthly visits to the home by a service manager who completes a report. Audits are carried out periodically to include health and safety, financial and an audit called ‘first impressions’. Service user feedback on the service is also sought on an annual basis. It is good that health and safety audits are completed but the frequency does not meet Tracs own target of three monthly. For example the audit of service user bedrooms for health and safety risks was last completed in January 2006. This needs to be done more frequently to ensure service users bedrooms are safe and do not pose risks to the individual or others in the home. Risk assessments had been completed for the premises, however the scoring system regarding the level of risk had been inaccurately completed. Instead of multiplying the scores staff had added them, this had resulted in some risks that should have been assessed as having a high priority being recorded as a lower risk. Whilst the majority of risk assessments had been reviewed some had not taken into account the significant changes to the premises. For example the risk assessment regarding smoking in the lounge did not reflect that the home has a smoking room. As previously stated in standard 9 of this report improvement is required to ensure satisfactory risk assessments are available for all identified risks to service users. Fire records showed that staff test the fire equipment regularly to make sure it is working. Regular fire drills are held to make sure that staff and service users would know what to do if there was a fire. Further thought needs to be given to control measures for identified risks. For example the recorded control measure for risk of fire in the boiler room was that a smoke alarm was fitted. Other control measures could include the restrictions on storage of items in this area, checks of the area, fire doors etc. The workplace fire risk place was observed to be over twelve months old and therefore needed review. The Manager said that the week before a new risk assessment had been completed by an external company and that she was awaiting their report. As previously required a smoke detector has been fitted in the laundry to ensure the fire alarms sound if a fire occurs in this room. Systems are in place to monitor the temperature of the fridge but the records did have some gaps, also some entries showed that the fridge temperature was too high. There was no evidence to show that action to reduce the temperature had been taken to reduce the risk of food poisoning to service users. Greenhill Road, 29, (westholme) DS0000016713.V297391.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 3 2 2 3 X 4 1 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 2 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 1 3 X 1 2 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 3 X X 1 X Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA2 Regulation 14(1,a) Requirement A full pre-admission assessment must be undertaken prior to offering the service user a place in the home. Outstanding requirement from 01/12/05. Trial visits must be used to fully explore the suitability of the potential service user to the home, and existing service users. Outstanding requirement from 01/12/05. TRACS and the service user or their representative must sign all contracts. Outstanding requirement from 01/02/06. All service users must have a care plan that details their needs, and wishes and how these are to be met. Outstanding requirement from 01/02/06. Goals must clearly state how they are to be met, who is responsible, and how it will be known if they have been achieved. Outstanding requirement from 01/02/06. DS0000016713.V297391.R01.S.doc Timescale for action 13/08/06 2. YA4 14(1,c) 13(6) 13/08/06 3. YA5 5(1) 13/08/06 4. YA6 15(1,a) 30/07/06 5. YA6 12(1,a) 15(2,b-d) 13/08/06 Greenhill Road, 29, (westholme) Version 5.2 Page 27 6. YA23 13(4,a-c) Unmet from the previous two inspections. Risks that service users pose to each other due to their complex and sometimes challenging needs must be assessed and control measures explored and implemented. Risks identified during assessment or care practice must be assessed and control measures implemented. Outstanding requirement from 01/12/05. Risk assessments must be reviewed at the set intervals (At least six monthly) and sooner if needs change or following a critical incident. Outstanding requirement from 01/12/05. Ensure staff practice ensures that personal information about service users is handled in a confidential manner and respects the privacy and dignity of individuals. A range of interesting and varied activities must be offered to service users. Ensure an auditing system is in place to effectively track that planned activities have taken place, and if not, the reason why. Service users who are at risk of self-neglect must have this need underpinned with a plan, and risk assessment. Outstanding requirement from 01/12/05. Ensure records used to monitor personal care to include the personal care matrix and continence charts are completed consistently. 30/07/06 7. YA9 13(4,a-c) 30/07/06 8. YA9 13(4,a) 15 30/07/06 9. YA10 12(4a) 13/07/06 10. YA12 16(2,m-n) 30/07/06 11. YA13 12(1) 16(2,m-n) 13(4,c) 12(1,a) 13/08/06 12. YA18 30/07/06 13. YA18 12(1) 30/07/06 Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 28 14. YA19 12(1,a) 13(1,b) Unmet from the previous two inspections. The provider must ensure all relevant healthcare monitoring is undertaken. Where a health concern has been identified ensure the service user has access to medical advice without delay. Not assessed at this inspection. Indicators of service users mental well-being must be included in the service users plan, or clearly signpost the reader to this information where this care is required. The drugs fridge temperature must be taken consistently. The drugs fridge must be repaired or replaced. All administered medicine must be signed for, or the relevant code entered onto the Medicine administration record. Tracs must review the adult protection training provided to staff to ensure it is adequate for staff and enables them to recognise potential abuse and respond appropriately to protect service users. Financial procedures require review to include the availability of bank statements and completion of cheque stubs to ensure service users personal monies are properly safeguarded. Issues of general maintenance need addressing to include: - Resealing of worktop in Westholme kitchen. - Ensure lighting in all bathrooms is adequate. - Ensure all extractor fans are kept clean. 30/07/06 15. YA19 12(1,a) 13(1,b) 12(1,a) 13(1,b) 15 13/07/06 16. YA19 30/07/06 17. YA20 13(2) 30/07/06 18. YA20 13(2) 13/07/06 19. YA23 13(6) 13/08/06 20. YA23 12(1) 13(6) 30/07/06 21. YA24 23(2) 30/07/06 Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 29 22. YA24 23(2,d,j) 23. YA33 18(1,a) 24. YA34 19 Provide a written schedule for 30/07/06 remaining outstanding work to the home to include fitting of new carpets and refurbishment of remaining bathrooms and showers. Adequate numbers of staff must 30/07/06 be provided to safely meet service users needs, and to cover staff breaks. Outstanding requirement from 01/12/05. Unmet from the two previous 30/07/06 inspections. Recruitment records must evidence that robust checks have been undertaken prior to staff commencing work in the home. Unmet from the previous two inspections. Mandatory and service user specific training must be delivered to staff as required. Evidence this has been planned and delivered must be maintained in the home. Unmet from the previous two inspections. 25. YA35 18(c) 30/08/06 26. YA36 18(2) 30/07/06 27. 28. YA37 YA42 9 13(4,a-c) 29. YA42 23(4,a) All staff must receive supervisions at least bi-monthly, and a record of these maintained. An application must be made to 30/07/06 the CSCI to register a manager for the home. Ensure the risk assessments 30/07/06 completed by staff are accurate in their assessment of the level of risk and include all control measures in place. Unmet from the previous 30/07/06 inspection. The fire risk assessment must be developed to show control measures for concerns/issues Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 30 30. 31. YA35 YA42 13(4) 23 13(4) 32. YA42 13(4) that have been raised. (Manager states this is in progress and the home is awaiting copy of the updated assessment.) Ensure all staff receive refresher fire training on a six month frequency. Ensure the reviews of risk assessments for the premises take into account the recent significant changes to the environment. Ensure the fridge temperatures are monitored on a daily basis and action is taken if temperatures exceed safe levels. 30/07/06 30/07/06 13/07/06 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. Refer to Standard YA17 Good Practice Recommendations Review the system for recording of meals offered to service users to provide a more effective method of determining if a healthy and balanced diet is being provided. Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Greenhill Road, 29, (westholme) DS0000016713.V297391.R01.S.doc Version 5.2 Page 32 - 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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