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Inspection on 30/10/07 for 29 Greenhill Road (westholme)

Also see our care home review for 29 Greenhill Road (westholme) for more information

This inspection was carried out on 30th October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Admission procedures are satisfactory and ensure the home can meet people`s needs. Staff often ask the people living there what they think of the home and how it could be better. People who live at the home have an annual review. It is good that staff work with people before the review to seek their views. Support to people is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. The staff are very good at helping people stay in touch with their family. This includes making phone-calls, writing letters and in person. People have lots of fruit and vegetables and get the food they like.The home has a satisfactory complaints procedure that ensures complaints are appropriately investigated. Staff have training in how to meet the needs of people at the home so they can support them well. The premises is generally in good order, making the home a nice place to live. Each person has their own bedroom that is decorated in the way they have chosen.

What has improved since the last inspection?

Food is properly stored and is in good condition, and discarded when past its best or use by date so that people do not eat food that is in poor condition. The record of complaints now clearly shows the action taken in response to complaints received to show peoples concerns are acted on. Cheque stubs are now satisfactorily completed to ensure individuals monies are safeguarded from risk of financial abuse. A passenger lift has been installed, this will assist people who have mobility difficulties to access the first and second floors more easily. The lounge on Hilltop has been repainted so that it is in good decorative order. The office on Hilltop has been converted to a smoking room so that people who live on Hilltop do not have to use Westholmes facility. 50% of staff have achieved an NVQ in care so they have the skills and knowledge to meet the needs of the people living there.

What the care home could do better:

Care plans should be updated when people`s needs change so that staff have up to date information on how to meet individual needs. Risks to people living at the home need to be appropriately assessed and measures in place to reduce the risk need to be clear. Staff need to ensure that people`s weight is recorded correctly and if there has been a change that they report this. The people living there should be supported to have regular dental check ups. This will make sure that individual`s health needs are identified and can be met. Improvement is needed to the medication administration to reduce the number of errors made by staff and ensure people get the medication they need safely.Work is needed to ensure the bathroom in Hilltop is in good decorative order. Improvements need to be made to staff recruitment, to include agency staff to ensure people are safeguarded from having unsuitable staff working with them. The format of the staff training records need review so that the reader can easily see all the training undertaken by staff. An application needs to be made to the Commission to register a manager for the home to ensure the home continues to be well managed.

CARE HOME ADULTS 18-65 Greenhill Road, 29, (westholme) Moseley Birmingham West Midlands B13 9SS Lead Inspector Kerry Coulter Key Unannounced Inspection 30 & 31st October 2007 09:40 th Greenhill Road, 29, (westholme) DS0000016713.V351185.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.V351185.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.V351185.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenhill Road, 29, (westholme) Address Moseley Birmingham West Midlands B13 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) suehullin@tracscare.co.uk Tracscare Group Ltd Denise Jean Stevens Care Home 14 Category(ies) of Learning disability (14), Physical disability (14) registration, with number of places Greenhill Road, 29, (westholme) DS0000016713.V351185.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) 6th December 2006 Date of last inspection 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. Westholme 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 up to four people working towards more independent living. It offers 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 its own facilities such as a lounge, kitchen, laundry and bathroom. The home has a large, mature garden at the rear. The home has its own transport, and is located close to local bus routes. The current scale of charges for living at the home, as recorded in the service user guide ranges from £1000 to £1400 per week. The fee information included in this report applied at the time of the inspection and the reader may wish to obtain more up to date information from the care service. Copies of CSCI reports are available in the home, on request. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out over two days; the home did not know the inspector was going to visit. This was the homes key inspection for the inspection year 2007 to 2008. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home – Annual Quality Assurance Assessment (AQAA). Three people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. Surveys were received from four people who live at the home, one care professional and five staff. People who live at the home were also spoken to during the visit. Their views of the home are reflected in the report. What the service does well: Admission procedures are satisfactory and ensure the home can meet people’s needs. Staff often ask the people living there what they think of the home and how it could be better. People who live at the home have an annual review. It is good that staff work with people before the review to seek their views. Support to people is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. The staff are very good at helping people stay in touch with their family. This includes making phone-calls, writing letters and in person. People have lots of fruit and vegetables and get the food they like. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 6 The home has a satisfactory complaints procedure that ensures complaints are appropriately investigated. Staff have training in how to meet the needs of people at the home so they can support them well. The premises is generally in good order, making the home a nice place to live. Each person has their own bedroom that is decorated in the way they have chosen. What has improved since the last inspection? What they could do better: Care plans should be updated when people’s needs change so that staff have up to date information on how to meet individual needs. Risks to people living at the home need to be appropriately assessed and measures in place to reduce the risk need to be clear. Staff need to ensure that people’s weight is recorded correctly and if there has been a change that they report this. The people living there should be supported to have regular dental check ups. This will make sure that individual’s health needs are identified and can be met. Improvement is needed to the medication administration to reduce the number of errors made by staff and ensure people get the medication they need safely. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 7 Work is needed to ensure the bathroom in Hilltop is in good decorative order. Improvements need to be made to staff recruitment, to include agency staff to ensure people are safeguarded from having unsuitable staff working with them. The format of the staff training records need review so that the reader can easily see all the training undertaken by staff. An application needs to be made to the Commission to register a manager for the home to ensure the home continues to be well managed. 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. Greenhill Road, 29, (westholme) DS0000016713.V351185.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 Greenhill Road, 29, (westholme) DS0000016713.V351185.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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements generally ensure that prospective residents have the information they need to make a choice about whether or not they want to live there. Arrangements are in place to ensure that before people move into the home an assessment is completed to ensure their needs can be met there. EVIDENCE: Copies of the home’s Statement of Purpose and Service User Guide were observed to be readily available to people in the home. These documents were observed to need updating to reflect the new management arrangements in the home as the registered manager had now left. The AQAA questionnaire completed by the Acting Manager acknowledged that they could be reviewed and kept up to date more often. Discussion with the Acting Manager indicates that it is Tracs intention to specialise in the brain injury client group at this home and so they will not be admitting any future people to this home who have a learning disability. It is recommended that this information is included in the Statement of Purpose so that people who live at the home and people who are thinking of moving there are clear about the service offered. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 10 One new person who had been admitted to the home since the last inspection was case tracked. An assessment had been obtained from their social worker prior to them moving in, Tracs also completed their own assessment to make sure they could meet the persons needs. Discussion with the Acting Manager indicates that the person did not visit the home prior to admission as they were admitted as an emergency. A review was organised for the person thirteen weeks after they were admitted to ensure they were happy at the home and that their needs were being met. One social worker commented that they found the thirteen week review very effective. Files sampled for three people, including one person recently admitted to the home showed that people are provided with a copy of the terms and conditions (contract) of their stay. These were seen to detail the fee for the home and had been signed by the person. The AQAA questionnaire completed by the Acting Manager records that the home hopes to further improve on the details in the contract in the next twelve months. Greenhill Road, 29, (westholme) DS0000016713.V351185.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning systems are generally satisfactory and provide staff with most of the information they need to effectively meet people’s individual needs, however plans need to be updated in a timely manner when people’s needs change. Risk assessments need further development to ensure that risk to people are managed in a safe and responsible manner and that staff have enough information to manage these risk. The people living there are supported to make choices and decisions about their day-to-day lives. EVIDENCE: The records of three of the people living at the home were looked at. These included an individual care plan that stated how staff are to support the individual with their daily routine, sleeping, diet and nutrition, mobility, finances, health, their communication needs, the things they like and dislike including activities and leisure interests, the things they need help with and the things they can do on their own. Behaviour guidelines were observed to be Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 12 available where needed and included triggers to behaviours and guidance for staff on how to respond. People who live at the home have an annual review. It is good that staff work with people before the review to seek their views and they are encouraged to attend their review meeting, which includes staff, relatives or advocates and other care professionals as appropriate. All of the care plans sampled had been reviewed and updated in the last six months. One person had a fall a few days before the inspection visit and their foot was in plaster. This meant that this person needed more support than usual. Their care plan had not been updated to reflect this. This needs to be done so that staff know what support the person now needs. People had clearly made choices within their care plan, for example completing declarations about how often they wanted to be checked during the night by staff. Staff were observed to consult with people during the visit, for example before the Inspector went into people’s bedrooms staff first checked with the individual for their permission. It is good that peoples meetings are held. One person who lives at the home said that meetings are held regularly. Issues discussed included activities, holidays and college courses. Tracs also holds an annual ‘focus day’ where people from across all the homes in the area have the opportunity to attend and are consulted about their views of the service. Risk assessments had been completed for people and were wide ranging and included fire evacuation, risk of falls, accessing the community, money handling, bedroom cleanliness, access to the kitchen and water temperatures. Some improvement was needed to the risk assessment process as not all assessments were up to date and not all clearly identified the measures in place to reduce risks. For example one person who has a history of falls had a manual handling risk assessment but this was last reviewed in March 2006. It recorded they needed 1:1 support from staff when walking but then in brackets stated ‘sometimes’. It was therefore unclear when they needed staff support. One person had a risk assessment for falls, this did not include all the control measures that were currently in place at the home. The assessment was recorded as reviewed in August 2007 but the review stated the assessment ‘needs to be rewritten’. This had yet to be done. This needs to be done to ensure that staff are all aware of how to support this person to reduce the risk of them falling. Greenhill Road, 29, (westholme) DS0000016713.V351185.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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the people living there experience a meaningful lifestyle. The people living there are offered a healthy diet and said that they enjoy their meals. EVIDENCE: Sampled records and discussion with people who live at the home show that a wide variety of in house and community activities are on offer. Each person has their own activity schedule, activities include attending day centres, college, shopping, swimming, cinema, walks, pub, the library, music, visits to local parks and bowling. During the visit staff offered people the opportunity to participate in activities, several people went out with staff for a meal, one person went to the hairdressers and one person played dominoes with staff. Others chose to watch the TV, read the newspaper or just spend time in their room. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 14 Activities are encouraged that provide opportunities for personal development, this includes cooking, computing and shopping for food. One person has recently completed a certificated course in food hygiene and has now enrolled on a sign language course at an adult education centre. People’s cultural and religious needs are respected and staff support people to attend a church of their choice, one person is regularly offered the chance to visit an Afro Caribbean community centre. Observation of the notice board in the home shows that people are kept informed of events in the area so that they can chose where they would like to go. One person who lives at the home said that activities that people would like to do are discussed at the residents meetings. Records are kept of activities undertaken, it was discussed with the Manager that these would be improved by including more detail about if the activity had been enjoyed. This will contribute to the future planning of activities. There was evidence in care notes and when talking with people that family contact is maintained. This can be in person, by letter and phone. Details of people’s family birthdays are recorded in care files so that people can be supported to send birthday cards. One person said that he goes to the library to e-mail his family every week. The rights of people who live at the home were respected by staff. For example people 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. Discussion with one person indicated they had been given a key to their bedroom and the front door of their home. One person commented that it was a ‘nice place to live’. Meals are usually cooked by staff for the people who live in Westholme whilst people who live in Hilltop are more independent and usually cook their own meals with support. Menus showed that a variety of food is offered that includes fresh fruit and vegetables. Records and discussion with staff show that culturally appropriate foods are on offer. One survey received from a social worker said they ‘make a great effort to provide culturally desired food’. People were asked what they thought of the meals during the inspection visit, comments included ‘food is nice’, ‘quite nice’ and one person said they could choose the food they wanted. One person commented that the bread purchased was a ‘cheap brand’ however it was observed that the bread in stock was of good quality and available in white or wholemeal. The Commission received an anonymous complaint about the home in August, part of this complaint was about the quality of the food. This was passed to Tracs to investigate who found that the food was of satisfactory quality. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 15 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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care records do not always clearly show how people’s health needs are being met and in some cases this could place them at risk of poor health. Improvements are needed to the medication system to ensure people receive their medication safely and as prescribed by the GP. EVIDENCE: Care plans sampled stated how individuals are to be supported with their personal care. Attention was observed to be given to individual’s personal care. The people living there were dressed appropriately to their age, gender, the weather and the activities they were doing. Each person had an individual hairstyle and it was evident that people had their hair cut regularly so that their appearance was well maintained helping to maintain their self - esteem. One person said they were not happy with how the hairdresser had done their hair so it was good that staff took them back to the hairdressers that day. One person who had recently fractured their ankle was supported by staff to be comfortable with their foot resting on a cushion. The healthcare needs of three people living at the home was tracked. Healthcare records were looked at to make sure people are offered regular Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 16 health checks. One persons care plan recorded that they need to go to the dentist every six months but their health record showed they had not been to the dentist for ten months. For one person it was not possible to assess if they had attended recent dentist and optician check ups as the Manager was unable to locate this persons health records. This person had a weight record that showed fluctuating weight to include the loss of 8lbs in one month. Due to the unavailability of the health records it was not possible to establish if medical advice had been sought about this person’s weight. The Manager did not know if GP advice had been sought as it occurred prior her starting work at the home. The Manager contacted the Commission shortly after the inspection to say that the records had been found and it appeared the GP had not been consulted at the time. Records show that where people need specialist health input they are referred, one person is currently on a waiting list for a physiotherapist assessment. Records showed and it was observed that staff follow the advice of health professionals to ensure individual’s health needs are met. Some people have health conditions such as epilepsy. It is good that where this is the case individuals have a care plan detailing the support they need should a seizure occur. The training matrix shows that nine staff have completed medication training. The Manager said that a further five staff are currently enrolled on medication training via a college. Only staff who have been trained to do so administer medication. In the last five months four medication errors have been notified to the Commission, two of which involved the same member of staff. Training records show this member of staff has since attended medication refresher training. It was discussed with the Manager if staff competency to administer medication is reassessed following an error. The Manager said she thought it had been done in this case but was unable to provide any evidence of this. Medication is stored in a locked cabinet. A tube of opened ointment was being stored that had been dispensed in June. As the tube had not been dated on opening it was not possible for staff to establish how long the ointment had been opened. Most creams and ointments should be discarded 28 days after opening. The Manager was advised to discard the ointment and order a new supply. At the front of each person’s Medication Administration Record (MAR) there was a photograph of the individual so it is clear whom the medication is to be given to. 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. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 17 Where people had been prescribed medication ‘as required’ there were for most individuals an up to date written protocol guiding staff as to when the medication should be administered. However for one person there was no protocol available for one of their medications that relieves constipation. This was of concern as the MAR directed staff to give 5 or 10 mls of the medication. Staff need clear guidelines about when to administer this medication and how much to give so that the individual is not put at a higher risk of discomfort or pain from constipation. Medication administration records were sampled. Most had been satisfactorily completed but some gaps were observed on four records where staff had not completed the record to indicate if medication had been administered. For some people this medication was not in their blister pack indicating it had been given but not signed for. For others the medication was still in the blister pack but there was no record of why the medication had not been given. The home has its own system of having a witness sign a separate record as a safeguard when administering medication. Observation of the witness record shows this system is often not used by staff. The AQAA completed by the Manager stated that robust procedures were in place for all aspects of medication administration. Whilst robust written procedures are in place these are not always being followed by staff. However the AQAA did acknowledge that medication competency audits needed to be completed more regularly for staff. Discussion with the Manager shows she recognises medication practice needs to improve, the Manager said she intends to do this by introducing more medication audits and changing to a pharmacist who will be able to offer the home advisory visits. Greenhill Road, 29, (westholme) DS0000016713.V351185.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 good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the views of the people living there are listened to and acted on so as to improve the service. The people living there are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure was clearly displayed in the hallway along with complaint forms, the procedure is also included in the service user guide. Surveys received from people who live at the home recorded that they were all aware of how to make a complaint. One person spoke about a complaint they had made, they said they had felt supported and have always been told by Tracs they have the right to live in a safe environment. It was good that this person has been kept fully informed about what is happening about the complaint, this includes being shown a copy of the notification form (regulation 37 form) sent to the Commission about the complaint. The home’s complaint log showed that they have received three complaints since the last inspection, to include one complaint received by the Commission and sent to Tracs to investigate. The complaint log showed all action that had been taken in response to the complaints. One complaint was made by someone who lives at the home about the behaviour of someone else who lives there. The person has complained that their behaviour is physically and verbally threatening. To ensure the person is protected from this type of behaviour the Manager has notified social services and this is being looked at under safeguarding adults procedures. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 19 Staff training records showed that staff have received training in the Protection of Vulnerable Adults (POVA) so they know how to identify different types of abuse and what to do if abuse is happening so they can protect the people living there. The training plan for this year includes the Mental Capacity Act. This came into force in April 2007 and is about assessing each person’s capacity to make decisions so it is important that staff know about this. In the files sampled, each individual had their own inventory of personal possessions. These were up to date. This shows that staff at the home assist individuals in looking after their possessions and have a system to monitor if anything goes missing. A money handling assessment is completed for each person to see what support they need from staff. Monies are checked daily by staff to ensure it is safe and none of it is missing but it would improve the safeguards in place if two staff did this rather than the usual practice of one staff signing the record. As required from the last inspection all cheque stubs are now appropriately completed so that people’s monies can be properly audited and safeguarded. Greenhill Road, 29, (westholme) DS0000016713.V351185.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, 26, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are sufficient to ensure that people live in a homely, comfortable and clean environment that meets their needs. EVIDENCE: A tour of the building was undertaken but not all bedrooms were observed. All rooms were found to be at a comfortable temperature. People who live at the home said it was kept warm. Part of the complaint received by the Commission about the home was that rooms were often cold, especially at night. This was investigated by the provider who found that people were generally happy with the temperature. However the investigating officer did recommend that the checking of room temperatures should be added to bedroom audits completed by staff. This has still to be done. At the last inspection work was underway to install a passenger lift, this has now been completed and will assist people who have mobility difficulties to access the first and second floors more easily. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 21 The home is generally well maintained and some rooms have been repainted since the last inspection, this includes the lounge in Hilltop. One person who lives in Hilltop confirmed that they had been involved in choosing the colour of the paint. On the first day of the visit there was a professional cleaning company at the home cleaning several carpets. The maintenance man was also at the home doing several odd jobs. The condition of the premises is audited monthly as part of the visit to the home by a senior Tracs manager. Their report for October identified that the grass in the garden was long and needed cutting. This was still the case at the time of the inspection visit. Discussion with the Manager indicates that the home does not have a gardener and that staff have to do this task. Consideration should be given to having a gardener regularly cut the grass or paving part of the lawn (after consulting people who live at the home) as currently it is a large grassed area that would be time consuming for staff to mow. Each person has their own bedroom. These are well decorated according to individual tastes and interests and were personalised. The ground floor bathroom has had a new assisted bath installed, this will make it easier for people who have mobility problems to have a bath. This has only recently been finished and some minor repairs are now required to one wall where the installation has caused damage to the décor. The Manager said this would be done soon. The bathroom in Hilltop was observed to require some attention as there were patches of mould on the walls, possibly due to a lack of ventilation in this room. The room did have a small window but this appears to usually be kept shut and there is no extractor fan installed. The home has a smoking room for the use of people who live at the home on the ground floor. Since the last inspection the office on Hilltop has also been converted to a smoking room so that people who live on Hilltop do not have to use Westholmes facility. The home was observed to be clean and free from offensive odours. Surveys received from people who live at the home indicate it is usually kept clean. One person said ‘home is spotless, people are always hoovering and cleaning’. Greenhill Road, 29, (westholme) DS0000016713.V351185.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. Arrangements are in place to ensure there are sufficient numbers of well trained staff to support the people living there so their needs can be met. Minor improvement is needed to how staff are supported and recruited to ensure that the people who live at the home are always supported by competent and suitable staff. EVIDENCE: Support to people who live at the home is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. 50 of staff have achieved an NVQ in care so they have the skills and knowledge to meet the needs of the people living there. In the surveys received, people who live at the home said that staff treat them well. One social worker’s survey included the comment that they had admiration for the way staff have handled difficult situations. Staff rota’s were sampled and these show that usually there are between five to seven staff on duty during the day, depending on who is at home and the activities planned. This appears to be sufficient to meet people’s needs. Staff surveys received indicate that staff are generally satisfied with the staffing Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 23 levels. Discussion with the Manager indicates the home has had some staffing vacancies and bank or agency staff have sometimes been used. The Manager said that four new staff have now been recruited, subject to satisfactory recruitment checks. Two staff records were sampled. These included the required recruitment records including evidence that a Criminal Record Bureau (CRB) check had been completed. For one person the outcome of the CRB check had not yet been received, but the home has received confirmation that this person was not on the protection of vulnerable persons register. To safeguard people at the home a protocol had been written and this member of staff does not work unsupervised with people. For one member of staff it was unclear from their application form and other recruitment records if they had been in employment prior to 2000. The Manager said that employment history was explored for staff at their interview and she would ensure this information was included in staff files. As stated earlier, due to staff vacancies the home has sometimes used agency staff. Discussion with the Manager indicates that the home does not routinely ask the agency for details of the agency staffs CRB check, experience and training history. This needs to be done to ensure that suitable staff are working at the home who have the right skills and experience. Staff surveys received indicate that staff are happy with the training they receive. One new staff spoken with said they felt well supported, had a good induction and had recently done a three day Studio III course. Staff training records were sampled. These showed that staff receive regular training. Some of this is done in house by watching videos and completing workbooks. Staff have received training that includes studio III (physical intervention), food hygiene, fire, first aid, medication, infection control and the protection of vulnerable adults. Some staff needed training in manual training and this is scheduled to take place in November. The home has a training plan for 2007-08. This showed that scheduled training includes mental capacity, managing clients money, infection control, fire, first aid and equality and diversity. It was time consuming to assess the training undertaken by staff as there is not one clear record that shows what training each member of staff has done. Three separate records had to be looked for each member of staff. It is recommended that the home reviews how it records training so that it is an easy process to see the training staff have done. The registered manager left in July and records show that staff supervision did not happen so frequently after this. However, there is a new acting manager in post and the supervision matrix shows that all staff have received a recent Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 24 supervision. As reported earlier in this report there have been some medication errors in the home. Staff supervision records did not show that this had been explored with the staff concerned. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 25 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, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current management arrangements ensure that the people living there benefit from a well run home but a permanent manager needs to be recruited and registered. The people living there can be confident that their views underpin all self-monitoring, review and development by the home. Arrangements are generally sufficient to ensure that the health, safety and welfare of the people living there is promoted and protected. EVIDENCE: The registered manager left the home in August, the home now has an acting manager who has transferred from another Tracs home. The acting manager has suitable experience and qualifications to manage the home. A decision needs to be made by Tracs about who is to manage the home permanently and an application needs to be made to the Commission to register the new manager. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 26 Staff surveys indicate the acting manager is supportive, one said ‘ new manager is very client orientated and open to new ideas’. One person who lives at the home said the acting manager was very approachable. Systems to ensure quality are in place, these include the views of people who live at the home, staff and others. Monthly visits to the home are made by a Manager who completes a report. Audits are carried out periodically to include health and safety, financial and an audit called ‘first impressions’. Where improvements needed are identified a ‘corrective action plan’ is formulated. Discussion with the acting manager indicates a staff strategy day is planned for November to look at how the home can improve. Minutes of meetings held with people who live at the home show they have also been asked to contribute towards ideas for development. Systems are in place to protect the health and safety of people at the home. Certificates were available to show that equipment such as the baths and electrical appliances are regularly checked to make sure they are safe for people to use. Staff test the water temperatures weekly to make sure they are not too hot or cold. When they were recorded as being higher than they should be, to ensure people do not get scalded this was reported and action taken to reduce the temperature. Staff test the fridge and freezer temperatures daily and records showed that these were within the limits for safe food storage. Where the temperature was too high on one occasion, the record showed action had been taken to reduce the temperature so that people were not put at risk of food poisoning. Certificates were available to show that the fire alarms and extinguishers are checked by an engineer. Records showed that a fire drill had taken place in October. Staff test the fire alarms regularly but on a minority of occasions the testing had not been done every seven days. This was brought to the acting managers attention who said she would ensure this was rectified. A gas engineer had visited the home the day before the inspection visit. The certificate issued showed that the gas appliances were safe to use but the engineer had made some minor recommendations, this included displaying an information notice for staff. The acting manager said that arrangements were being made to meet the recommendations. At the last inspection it was identified that an engineer had found the electrical installations in the home to be unsatisfactory, the home had therefore made arrangements for this to be rectified. This has now been done and a new certificate has been issued that shows the electrical installations are safe. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 3 3 X X 3 X Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 28 Yes, number 1. 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 YA9 Regulation 13(4) Requirement Risks to people living at the home need to be appropriately assessed and measures in place to reduce the risk need to be clear. Outstanding requirement from 6/1/07. Where monitoring of individuals weight shows substantial weight loss or gain medical advice needs to be sought to ensure this is not caused by an underlying health condition. Protocols need to be completed for all medication that is prescribed on an ‘as required’ basis to ensure people are given the medication they need. Medication administration records must be satisfactorily completed to show that people receive their medication as prescribed. Ensure there is adequate ventilation in the bathroom on Hilltop and that the bathroom is repainted so that it is in good decorative order. An application needs to be made to the Commission to register a manager for the home. DS0000016713.V351185.R01.S.doc Timescale for action 31/12/07 2 YA19 12 (1) 31/12/07 3 YA20 13(2) 31/12/07 4 YA20 13(2) 31/12/07 5 YA24 23(2) 28/02/08 6 YA37 10 30/01/08 Greenhill Road, 29, (westholme) Version 5.2 Page 29 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 YA1 Good Practice Recommendations The statement of purpose and service user guide need to be updated to reflect the new management arrangements in the home. Information about Tracs intention to specialise in the brain injury client should also be included so that people who live at the home and future residents are clear about the service offered. Care plans should be updated when people’s needs change so that staff have up to date information on how to meet individual needs. The people living there should be supported to have regular dental and optician check ups to ensure their health and well being. Medication competency assessments should be completed for staff where medication errors have been made to ensure medication is safely administered to people in the future. Creams and ointments should be dated on opening and discarded after 28 days to ensure they remain effective. The checking of bedroom temperatures should be added to the bedroom audit to ensure rooms are maintained at a comfortable temperature. (as recommended from Tracs own complaint investigation) Consideration should be given to having a gardener regularly cut the grass or paving part of the lawn (after consulting people who live at the home) as currently it is a large grassed area that would be time consuming for staff to mow. Audit staff files to make sure clear information is available on staff’s previous work history to evidence that robust recruitment procedures have been followed. Profiles of agency staff used by the home should be available to show that Criminal Record Bureau checks have been undertaken and the individual has the right experience and training to work with people. The format of the staff training records need review so that the reader can easily ascertain all the training undertaken by staff. DS0000016713.V351185.R01.S.doc Version 5.2 Page 30 2 3 4 YA6 YA19 YA20 5 6 YA20 YA24 7 YA24 8 9 YA34 YA34 10 YA35 Greenhill Road, 29, (westholme) 11 YA36 12 YA42 Improve the recordings of staff supervisions to clearly show that care practice is discussed and guidance given where improvements are needed, for example where medication errors have occurred. Review the procedure for carrying out tests of the fire alarms to reduce the risk of the duration between tests exceeding seven days. Greenhill Road, 29, (westholme) DS0000016713.V351185.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 Greenhill Road, 29, (westholme) DS0000016713.V351185.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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