CARE HOME ADULTS 18-65
Halas Home Wassell Road Hasbury Halesowen West Midlands B63 4JX Lead Inspector
Mrs Jean Edwards Unannounced Inspection 16th October 2006 08:30 Halas Home DS0000024952.V316119.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 Halas Home DS0000024952.V316119.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. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Halas Home Address Wassell Road Hasbury Halesowen West Midlands B63 4JX 0121 501 3604 0121 585 7821 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) Halas Homes Kathryn Rudge Care Home 37 Category(ies) of Learning disability (37) registration, with number of places Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Includes 2 satellite houses at 64 and 66 Wassell Road. Service users may remain at Halas Homes when they reach age of 65 years for as long as the home can demonstrate it can meet their needs. Within the 37 registered beds, two beds may be used for new admissions of up to 2 older people (over 65 years) with a learning disability (LD (E)). Date of last inspection Brief Description of the Service: Halas Home is located on a residential housing estate near to Halesowen town centre. The Home comprises a large detached property, in its own grounds and a cluster of two small, semi-detached, ex-council houses. These houses have frontages onto Wassall Road, with rear access onto the grounds of the larger property. Situated within the grounds is a detached building, which is used for small group activities and meetings. The Laundry is located in another detached annexe to the main building. The Home currently provides care and accommodation for up to thirty-seven people with a wide range of learning disabilities, whose ages range from early 30s to mid 80 years of age. The second floor of the main building has been converted to provide two semiindependent living flats for service users who are able to practice independent living skills. The main house has two lounge areas and a conservatory on the ground floor, twenty-eight residents are accommodated in a range of bedrooms on the ground and first floors and there are bathing/showering facilities and toilets throughout the building. The large kitchen in the main building supplies food stocks for the complex and provides a cooked main meal for everyone on a daily basis. The Home has a staff team of 50 people including the Registered Manager and is supported by the Voluntary Organisation, run by a committee of volunteer members. The level of fees at this home ranges from £387.60 to £651.15 per week, generally according to individual needs. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key unannounced inspection has been conducted by an Inspector from the Commission for Social Care Inspection and has taken place over one weekday between 8:20 a.m. and 7:20 p.m. The purpose of the inspection visits has been to assess progress towards meeting the Care Homes Regulations 2001 and National Minimum Standards for Younger Adults. The range of inspection methods used to obtain evidence and make judgements includes discussions with the registered manager, assistant manager, operations manager, finance manager, seniors and other staff on duty. There has been contact with professionals associated with the home and discussions and observations with the majority of residents living at the home, some of whom do not have verbal communication skills. A number of records and documents have been examined, including responses to a recent anonymous complaint. Other information was gathered prior to the inspection visit, from reports of visits undertaken by the organisations representative and pre inspection questionnaire submitted by the home. Twenty service user surveys were sent to the home by the CSCI and the home made additional copies available to all residents able to respond. An analysis of the 31 copies of survey forms returned is contained throughout this report. Comments have been very positive about the home and staff. What the service does well:
The registered manager and organisation have responded to the previous inspection report with a comprehensive action plan, giving dates for the required improvements to be put into place, and the majority are completed. The organisation has produced copies of a range of information in alternative formats, using pictures and symbols suitable for residents and other people unable to easily understand written information. Examples are the service user guide and complaints procedure, which help residents to understand and be aware of the services provided and be able to use the complaints process if they need to. The majority of residents are able to make their own choices and are able to express preferences and pursue their own individual lifestyles, with some people choosing to attend day activities provided by the Local Authority. Other people are encouraged to attend daytime activities provided by staff from Halas Homes in a separate building in the grounds. They are currently making items ready for a Halloween party due to take place at the home. The majority of residents also have hobbies and interests outside the home, for example attending the Gateway Club, going to the cinema and attending sporting
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 6 events such as football or swimming. Some people enjoy visits to the hairdressers or reflexology treatments in Stourbridge. There are also organised trips to places such as Cadburys world. A senior carer arranges regular entertainment to take place in the home; examples are a group performing a pantomime, clowns, a chocolate party, singers and exercises to music. The residents are supported to go away for holidays according to their personal preference. Small groups of residents have enjoyed summer holidays in Somerset and at an adapted hotel in Blackpool, which has been greatly enjoyed by the people who have stayed there. Further holidays for small groups of residents and staff are due to take place in November 2006. Staff and residents spoke about going out each day after breakfast to visit Madame Tussauds and spending a whole day at Blackpool Tower, where there is a circus, ballroom and views from the top of the tower. A number of residents continue to attend church services and be part of the social life of churches. Some people go to the Catholic Church, others to the local United Reform Church, travelling by their preferred mode of transport. Most people continue use the Ring & Ride service and one person likes to travel by taxi. Two residents have visited Lourdes this year on a trip organised by the local Catholic Church and they say they would like to make the trip again next year. Residents meetings continue to take place on a regular basis, with a wide range of topics discussed and opinions freely given about the running of the home. The results of the CSCI service user survey confirm that the majority of residents know meetings take place to talk about whats good and what should be changed at the home. The local pharmacist has recently attended a meeting with residents to discuss with them the importance of their medication and how they can help staff by telling them about any symptoms, pains or changes. The home is clean, tidy and homely. All residents each have their own bedroom, decorated and furnished as they wish. Some people choose to have keys and are able to lock their bedrooms for privacy. Three residents live semiindependently in the flat on the second floor, using its kitchen facilities to make their own drinks and snacks. The menus show colourful descriptive pictures of the meal options and there is a food council made up of 16 residents, catering staff and carers, who hold regular meetings to assess and comment on the food provided. Halas Homes continues to have a stable staff group many of whom have worked at the home for a long time and know the residents well. They are caring, committed and flexible, often willing to work extra shifts, especially to support residents with outings and trips away from the home. There continues to be strong commitment to undertake training, which benefits the residents. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 7 The organisation has made excellent progress to make sure that all staff receive appropriate training to give them awareness of challenging behaviour and issues relating to the protection of vulnerable adults. The organisation continues to build on its strong commitment to staff training and development with a ratio of 59 of care staff qualified to the NVQ level 2. In addition there are senior staff undertaking the NVQ level 3 award. The operations manager provides appropriate awareness training in Equal opportunities, Racism and Disability awareness for all staff. There has been a lot of friendly repartee between the members of staff and residents during the visit. During discussions and observations staff have shown a dedicated approach to their work; they clearly know the residents’ likes and dislikes and how to meet their needs. The responses to the CSCI survey indicate that the majority of residents like living at the home, feel well cared for, indicating that staff treat them well and always listen to them. To the question on the CSCI service user survey, whats good about living at your home, some responses are: everything, gardening,... girlfriend, staff & care worker, bedroom, friends I share with, bedroom, activities, have good friends here, I am looked after well, my clothes are washed and ironed and Im well fed. My room is clean and tidy. food, friends, trips, holidays and no bills to pay and I like it here, I am happy, I like the staff and the other residents. This inspection was conducted with full co-operation of the registered manager staff team and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank the management, staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection?
The organisation has made good progress to show that there have been multiagency discussions and decisions made with each person about all lifestyle choices, which include the management of finances and any limitations on choice. Steps have been taken to establish each persons level of ability and the process to develop financial care plans are in progress with the aim to have individual bank accounts for residents wherever this is possible. The registered manager and senior staff have made good progress to expand and develop written assessments of known risks. They are in the process of finding ways to minimise and manage risks with the residents, especially relating to each persons personal safety, activities, holidays and so on, with records of findings held as part of each residents plan. The redecorating and renewal programme is continuing with improvements to residents bedrooms and the flat roof over the Garden Wing has been
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 8 renovated. A new shower room, with new anti-slip flooring has been created on the first floor of the main house providing improved choices of bathing facilities for residents. There is a planned programme of work for the small satellite houses, with renovation to one of the lounges following a leak from the shower. The kitchen and flooring is going to be renovated and the whole premises are going to be repainted, with colours chosen by the residents. Work to repaint the communal areas will take place during night hours to avoid disruption for residents living there. There is also an on-going programme to replace fire doors in the home. The laundry has been extended and completely renovated to provide separate washing and drying areas, as well as an ironing station with a state of the art commercial iron. There are also 2 commercial washers and 2 commercial tumble dryers. The work to the grounds, the main house and around the outbuildings have been completed and now provide attractive surroundings. The sensory garden is a particularly peaceful and pleasant area, with herbs such as lavender, sage and thyme and there is a memorial statue called Peter & Dog, a water feature, and seating area around a mature tree. The registered manager has taken action to make sure that improvements have been made to health and safety at the home. For example the weekly fire alarm checks are now conducted and recorded consistently, and a regular written accident analysis has been resumed to highlight any trends or increased risks, which need to be controlled. What they could do better:
The registered person must continue the development of the care planning processes to make sure each persons plan is centred around their individual needs and is in a format that they can understand, such as large print, pictures or symbols. There must also be short term care plans to provide information and guidance for additional care needs for example if residents are unwell and need additional medicine, care and attention. The home uses individual activity records, however these need to be expanded to show whether the resident has enjoyed the activity or why they have refused to participate in a particular activity. The home has a generally good system for the administration of residents medication, however this visit has identified a small number of areas needing improvement including a request to the pharmacist under contract to provide medication to the home to make regular visits to check the medication system and provide support and advice. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 9 The organisation has given a commitment to safeguard residents by making sure that all radiators and exposed pipe work is guarded. This work must be completed within the agreed timescale. The home is providing care and accommodation for a large number of residents in three separate houses. Some residents now have more complex needs and one person in particular has changes to behaviour patterns, which require more staff support and supervision. Therefore the registered persons must increase the number of care staff on duty in the main house on afternoon and evening shifts to provide the additional support and supervision for the safety of all residents and staff. The home operates a structured system of formal staff supervision meetings on a one to one basis. These must be increased to consistently provide all care staff with a minimum 6 supervision meetings each year. The meetings must be seen as beneficial, with work related topics recorded and agreed by both parties. The registered manager must make sure that minor improvements are made to health and safety at the home, for examples a formal asbestos risk assessment must be conducted by a competent person to comply with recent legislation and a copy of the up-to-date Landlords Gas Safety certificate must be forwarded to the CSCI office, Halesowen. 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. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 10 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 Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 11 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): 2, 3, 4, 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is good evidence that all residents needs are assessed and reviewed, with multi-disciplinary health care professionals. The home offers good, clear information about the service, including updated residents contracts / terms and conditions of occupancy. This has the effect that residents and their advocates have sufficient information regarding their rights and entitlements and any agreed restrictions. The home actively encourages introductory visits and there is documentary evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. EVIDENCE: The organisation has developed clear information to help residents understand what services the home can provide, through the service user guide, which includes pictorial illustrations, discussed with existing residents as meaningful to them. The home has a clear admission criteria and the admission of new residents is only agreed after a summary of the care management assessment and a copy of the care plan has been received; and the registered manager has
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 12 undertaken a full needs assessment to ensure the home can meet the persons assessed needs. From discussions and examination of a sample of recent new admissions to the home there is good evidence that the assessment is conducted professionally and sensitively and involves the resident, and their family or representative, where appropriate. The sample of residents files the home has comprehensive assessment information and there is evidence of periodic reassessment, which is good practice. In addition the registered manager seeks reviews and reassessments for any resident with changing needs. An example is a current resident with dementia associated with learning disability, where there are changes to behaviour patterns, with attempts to abscond and display aggression at times. Discussions with staff and examination of documentation provide evidence that specialist services have been accessed, such as the intensive support service, as needed. It is evident that the registered manager only agrees to admissions of new or existing respite stays if she is confident that the staff team have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Residents, records and staff confirm that prospective residents are given the opportunity to spend time in the home. This may include a number of visits and overnight stays. The home allocates a member of staff to give information and to help the person understand how the home is organised and run and explain what facilities and services are available. Throughout this visit the members of staff were seen to be communicating effectively with the residents. The sample of residents case files examined demonstrate that residents are provided with a Contract / Terms and Conditions, which sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the resident in an easy to understand format. The organisation demonstrates good practice making sure that the contract / terms and conditions are reviewed on a regular basis and reflect good practice guidance, for example from the Office of Fair Trading. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 13 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, 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care planning system continues to improve and generally provides staff with the information they need to meet each person’s needs. The home plans to develop a more person centred approach to the planning process so that residents have as much control as possible over their lifestyle and care. Risk assessments continue to be expanded to cover all aspects of personal and social, and health care; this improves protection for residents. EVIDENCE: From the examination of residents case file and discussions it is evident residents have a care plan in place. The residents or their relatives or representatives, where appropriate are actively involved and have signed the plans to indicate their agreement. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 14 The care plans, do not yet demonstrate that they are developed following person centred planning principles and they are not as yet in formats that residents can easily understand the information. Plans must be written in plain language, which is easy to understand and considers all areas of the person’s life including health; specialist treatments, personal and social care needs. There is evidence that the home is developing the staff team to have skills and ability to support and encourage residents to be more actively involved in the ongoing development of their plan. The home operates a key worker system, which enables staff to establish special relationships and work on a one to one basis. It is noted that the registered manager acts as key worker for a small number of residents and it is strongly advised that she delegates this role to care staff to free up managerial time for monitoring, and developing the service. Plans are reviewed regularly involving the resident and, where agreed, their families or representatives. Generally plans are updated and action taken to respond to any changes for example where there are long term changes to the persons physical or mental condition. However the care plans do not currently reflect short-term care needs, such as short term illness, for example where antibiotics and extra care is needed to deal with infections. The home is striving to ensure that all staff have awareness of current good practice and they actively promote the development of skills, including for some residents, independent living skills. The home is able to show that some residents have moved to supported living arrangements and the flat on the second floor of the main house provides semi-independent living accommodated for three residents, who use the kitchenette to make their own drinks and snacks. Care plans include risk assessment elements, which the registered manager and senior staff are continuing to develop. The management of risk generally takes into account the age, specialist needs of people who use the service, balanced with their aspirations for independence and choice. Where limitations are in place, the decisions have been made with the resident and their family or other professional workers. There are comprehensive risk assessments in place for residents participating in activities and holidays outside the home and recently risk assessments have been devised with the involvement of the Intensive Support Team for the resident who continually attempts to abscond. The home has a comprehensive computerised system for managing residents finances, which has been well established and has recently been revised to make it more transparent. It is very positive that action is now being taken to review all residents finances, which are held by the Organisation, with a view to providing individual residents accounts and promoting financial independence, where this is achievable. The home has obtained sample signatures from all residents who are able to meaningfully sign documents. The Finance manager has revised the financial policies and procedures relating to the homes management of residents monies and given copies to the CSCI
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 15 office Halesowen for consideration and comment. These will be forwarded to the organisation in separate correspondence. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 16 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): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Links with the community are generally good and planned and spontaneous activities take place. Residents are generally able to take advantage of and develop socially stimulating opportunities, including holidays away from the home. The menus are designed to consistently offer residents choices of healthy and good quality meals. EVIDENCE: The home demonstrates a strong commitment to enabling residents to develop their skills, including social, emotional, communication, and independent living skills. The assessment of a sample of residents case files and discussions with groups of residents and staff show evidence of structured activity programmes for some residents, whilst some residents prefer a more spontaneous approach
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 17 to activities. A senior member of staff has taken the role of organising and developing activities programmes in the home, the local community and trips and holidays away from the home. There is an activity planner and residents can access and enjoy the opportunities available in their local community, sometimes using public transport, sometimes using the homes vehicles, library services, the local pub, and local leisure facilities. Examples of trips and holidays include small groups of residents visiting Cadbury World, the cinema at Merry Hill, the chalet at Somerset, the Bond Hotel in Blackpool and Special Olympics in Lanzarote. The home ensures that education and occupation opportunities are encouraged, supported and promoted. A number of people continue to attend community based day opportunities for younger people organised by the funding local authorities. A number of older residents continue to attend day centres for older people, enthusiastically describing some of the activities and events organised there. Other residents choose to remain at home and are encouraged to participate in activities provided in a separate building in the grounds, enjoying, crafts, art and music. Residents are encouraged and supported to practice their faith, attending local churches according to their preference. Some people attend the local Catholic Church for services and socials, and others regularly attend services at the local Free Church. The majority of residents have the opportunity to develop and maintain important personal and family relationships, and some people are able to visit family members for weekend visits. Other people have family visitors at the home. The responses to the CSCI service user survey confirm that visitors and families are welcomed at the home. The registered manager and senior staff ensure that where it is appropriate residents are involved in the domestic routines of the home, for example they can take responsibility for their own room or help with tasks in the dining room and kitchen. One of the residents particularly enjoys helping the maintenance staff and gardener. Residents are involved in menu planning and assisting with meals. The cook is experienced and knowledgeable about residents dietary need and makes sure that they are able to enjoy the food they prefer and like. The home now has a food council, one resident proudly indicated her photograph displayed in the dining room, along with the other 15 resident members pictures. The food council monitors opinions about the meals and acts as a means of communication between the other residents, catering staff and management. The colourful pictorial menus are varied with a number of choices including healthy options. The home has started to introduce tasting sessions, which include a variety of dishes that encourage residents to try new and sometimes unfamiliar food. Some of the foods tried and liked are mackerel on toast and
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 18 pate on toast. Residents are complimentary about the food, saying there is always plenty to eat and lots to choose from. Fresh fruit, hot and cold drinks are readily available in the open kitchen area. Staff are aware of the needs of those residents who find it difficult to eat and offer sensitive assistance with feeding. They are aware of the importance of feeding at the residents pace, so that they feel comfortable and unhurried. A small number of residents have their meals, particularly breakfast at a different time, to allow them time and space to eat at their leisure. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 19 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health needs of residents are well met with generally good evidence of multi disciplinary working taking place on a regular basis. The systems for the administration of medication are generally good with clear and comprehensive arrangements being in place to ensure residents medication needs are met. EVIDENCE: Staff demonstrate that they have awareness and understanding of principles of offering personal support and are generally responsive to the varied and individual requirements of the residents. They recognise that the delivery of personal care is highly individual and has to be flexible and reliable. Staff are show sensitivity and attention is given to ensuring privacy and dignity when providing personal care for residents. Whenever possible residents are able to have choice about which staff provide their personal care and residents are supported and helped to be independent and responsible for their own personal hygiene and personal care, wherever it is possible for them to do so.
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 20 The records of daily care and support provided for each person have improved, however it is recommended that the home consider a checklist (for example monthly) for each person to demonstrate and monitor that their personal hygiene and health care needs have been provided in accordance with their preferences. There is evidence that residents have good access to health care services that meet their assessed needs both within the home and in the local community. The majority of residents are able to choose their own GP and attend local dentists, opticians and other community services. Health care professionals manage the health care needs of residents unable to access local services with visits to the home. Action has been taken to introduce appropriate ways to educate residents and help them to understand the need to regularly check themselves for any abnormal / unusual changes in their bodies. The home has obtained pictorial booklets, which are discussed at residents meetings and with residents on an individual basis. Residents are offered access to health care screening processes, with agreements, outcomes or refusals recorded in each persons case file. Staff are continuing to work with community nursing colleagues to implement Priority Screening for Health - health passports for each resident covering all aspects of well-being. Two of the sample of files examined needed to have information completed and updated with all current needs, especially as these are presenting challenges to the service. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. Where the medication system needs minor improvements, such as the inclusion of a homely remedies policy and consistent records of medication balances on MAR sheets the registered person has been responsive and is working towards improvement and she undertakes regular recorded management checks to monitor compliance, which is very good practice. The home has a training plan and makes sure that all staff involved in the administration of medication administration undertake training, which has accreditation. Staff have good access to training in health care matters and are encouraged and given time to attend seminars and lectures arranged by local health care organisations on specialist areas of work. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 21 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, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a comprehensive complaints system with some evidence that staff understand the need to listen and to act upon areas of concern. The complaints procedure has been provided in alternative formats for residents. Policies, procedures, guidance and staff training are in the process of implementation in order to provide residents with safeguards from abuse. EVIDENCE: The organisation has now developed alternative formats for the complaints procedure, which are more suitable for residents capabilities. There are no complaints made directly to the home recorded in the home’s complaints log since the last inspection visit. There has been one anonymous complaint made to the CSCI office, London in October 2006, relating to inadequate staffing levels and lack of care for a resident with changing needs. The CSCI required the organisation to conduct its own investigation. The home provided a swift and comprehensive response. There is an acknowledgement that some staff shortages have been recently been experienced, however staffing levels have been maintained with use of agency staff, where needed. Evidence has been provided of multi-agency involvement in the management and support for the resident with changing needs. Assessment of records, observations and discussions during this visit confirm the investigation findings. However the registered manager is now required to increase staffing levels in the main house during the afternoon and evening shifts to supervise and safeguard residents and staff whilst the situation remains.
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 22 The responses of the CSCI service user survey are confirmed during discussions with residents who say that they can voice any concerns either directly with the manager or staff. Discussions with staff indicate that they are aware of the homes procedures to safeguard residents and the local authority multidisciplinary procedure for the protection of vulnerable adults. The Home regularly arranges staff training in the areas of protection of vulnerable adults and the operations manager is exploring options of additional training provided by the neighbouring local authority, Sandwell MBC. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. The outcomes from a previous referral have been managed well with issues satisfactorily resolved. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 23 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, 25, 26, 27, 28, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standard of the décor within this home is generally good with evidence of improvement through ongoing maintenance. The home generally presents as a safe, homely and comfortable environment for residents. EVIDENCE: Halas Home provides accommodation for up to 37 adults with learning disabilities over a wide age range. The premises currently comprise the large three-storey house with two extended ground floor wings and two small (3bedded) satellite houses. During the tour of the premises there is evidence that the home continues to be maintained to high standards on an ongoing basis. There is evidence of improvements and planned refurbishments in the satellite houses, which demonstrate the active involvement of residents living there with their choice of decor.
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 24 There is continued progress to provide lockable space in residents bedrooms on a prioritised basis and bedroom locks and keys have been provided for residents wishing to have them. A new showering facility has been completed on the first floor of the main house, which offers residents a wider choice of pleasant environments for their personal hygiene needs. There are still a small number of unguarded radiators and places with exposed hot water pipes, and the ongoing work programme must be completed in an agreed timescale to safeguard all residents from the risks. The kitchen is well organised, with well maintained equipment, and a wide range of food stocks stored and prepared in good compliance with food safety. The homes laundry has been extended and new equipment has been installed. This laundry service continues to be well organised and the designated laundry staff achieve good standards of infection control. There is a laundry procedure and measures are in place for supplies of disposable gloves and aprons to be readily available in the laundry at all times. Throughout the home good standards of cleanliness continue to be maintained and there have been no discernable malodours during this visit. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 25 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, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a stable, enthusiastic, well-motivated staff team and the organisation continues to demonstrate a strong commitment to staff training and development to ensure residents receive consistent assistance and support to develop their potential. There are rigorous staff recruitment processes, which provide good safeguards for residents. EVIDENCE: The staff team at Halas homes is relatively stable, with 6 resignations since January 2006, for valid reasons. From assessment of the pre-inspection information, staffing rotas and discussions with the registered manager and senior staff it is evident that there have been occasions when the staffing levels have had to be supplemented by existing staff working extra shifts and use of agency staff. A major cause is a number of staff on long-term sick leave for very valid reasons, combined with some intermittent sickness absences due to chronic and seasonal ailments. There is evidence that this situation is being
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 26 managed and though it inevitably places additional stresses on some members of staff, most people appear cheerful and committed. Assessment of current staffing rotas at this visit shows that the home is generally maintaining adequate staffing levels. However further account must be taken of the number of recorded incidents relating to the resident who continually tries to leave the home and who has succeeded on a number of recent occasions. The resident has managed to leave the premises and has been found in nearby localities, sometimes willing to return with persuasion but on one occasion with police involvement and a level of physical aggression. Although it is acknowledged that additional control measures have been put in place, these have not been entirely successful and there are not sufficient numbers of staff on duty in the afternoons and evenings to monitor the situation and offer support to other residents and colleagues, at these high risk times. During discussions staff have shown that they are aware of the aims, policies and procedures of the home. It is evident that staff have a warm rapport with residents and families and are knowledgeable about their needs and preferences. A random sample of staff files assessed at this visit demonstrates continued commendable recruitment practice, with very well ordered staff files and comprehensive documentation. The organisation continues to demonstrate a strong commitment to staff training and development and is sourcing and providing all staff with appropriate training to raise awareness and skills to respond to residents changing needs. The home currently has a ratio of 59 of care staff with an NVQ level 2 care award or LDAF (Learning Disability Framework Award), with new candidates registered for training. It is strongly recommended that the organisation consider providing the accredited dementia training, Yesterday, Today & Tomorrow for all staff. Although all staff have an annual appraisal and there is a formal structured supervision system, not all care staff have received a minimum of 6 one-to-one supervision meetings. Notes of staff supervision sessions do not always reflect the work-related discussions or produce an action plan for personal development. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The registered manager is supported well by staff in providing clear leadership throughout the home with people demonstrating an awareness of their role and responsibilities. The systems for resident consultation at Halas Homes are good with a variety of evidence that indicates that residents’ views are both sought and acted upon. The compliance with all aspects of records and health and safety is satisfactory, which minimises potential of risks residents safety and well being. EVIDENCE: Mrs Kathryn Rudge is the registered manager for Halas Homes. She has a number of years of valuable experience in assisting the development and running the service. She continues to update her professional development
Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 28 and she attends and participates in workshops, and has undertaken the Registered Manager’s Award. The general manager, finance manager and operations manager, who has qualifications related to human resources and staff training, support her. The operations manager is making good progress to develop a comprehensive quality assurance system, which will be used for monitoring and self-evaluation of all service areas, using the National Minimum Standards as a basis. It is commendable that an analysis of the homes current position has been undertaken. There is an up-to-date annual development plan in place and the results of resident, relatives and stakeholder questionnaires issued in June 2006 have been collated and evaluated to identify the homes strengths and weaknesses. There are regular residents and staff meetings, with minutes available. The organisation continues with the excellent progress to develop applicable policies into formats, such as pictorial /audio/ video, which are suitable to residents capabilities. The sample of mandatory staff training records, fire safety and maintenance service records examined are generally satisfactory. The registered manager has taken action to ensure the weekly fire alarm checks are now conducted and recorded consistently. However at this visit a small number of improvements need to be made. There is currently no documentary evidence of the up-to-date Landlords Gas Safety service certificate or an asbestos risk assessment conducted by a competent person or organisation. Accident records have been examined and thee is evidence that the registered manager has resumed the regular documented accident analysis. There are 6 recorded accidents involving residents and 11 accidents involving staff since the last inspection visit. Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 4 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 3 2 2 X Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(1) Requirement To expand, develop and agree with each service user an individual plan, (person centred care plan), which may include treatment and rehabilitation, describing services and facilities to be provided by the Home, and how these services will meet current and changing needs, aspirations and achieve goals, and be reviewed six monthly (Timescale of 31/12/04 and 01/12/05 and 01/04/06 Not Fully Met though improved) Timescale for action 01/03/07 2 YA6 15(1) To devise short term care 01/12/06 plans to provide information and guidance for additional care needs for example during episodes of temporary illness, need for antibiotics etc. To provide evidence in the 01/03/07 service user plan of discussions and decisions made with each person about lifestyle choices, management of finances and any limitations
DS0000024952.V316119.R01.S.doc Version 5.2 Page 31 3 YA7 15(1)(2) Halas Home on choice. (Timescale of 31/12/04 and 01/12/05 and 01/04/06 Not Fully Met - In Progress) 4 YA7 15(1)(2) 20(1) 1) To establish each persons level of capacity and develop financial care plans accordingly, with the aim of agreeing a multi-agency strategy for individual bank accounts wherever this is possible 2) To provide individual receipts for each financial transaction for each resident 3) The organisation must ensure all records (including financial records fully comply with the Data Protection Act 1998) (Timescale of 31/12/04 and 01/12/05 and 01/04/06 Not Fully Met Good Progress) 5 YA7 15(1)(2) 20(1) To ensure inventories of 01/12/06 service users personal possessions are fully completed dated, signed and witnessed and thereafter kept up to date To implement behaviour 01/12/06 monitoring charts for any resident presenting behaviours which challenge the service or other people using the service (Timescale of 01/03/06 Not Fully Met) To expand service users activity records to record an evaluation of participation or refusal
DS0000024952.V316119.R01.S.doc 01/12/06 6 YA9 13(4) 7 YA14 13(1) 01/12/06 Halas Home Version 5.2 Page 32 8 YA20 13(2) 1) To expand the homes medication policy to include procedure for the administration of homely remedies 2) To ensure amount of medication received is consistently recorded on the MAR sheets 3) To record carried forward balances of medication on MAR sheets 4) To request regular (quarterly) audits from the pharmacy provider in accordance with contractual obligations To complete work to ensure that all radiators and exposed pipe work is guarded or has guaranteed low surface temperatures. (Timescale of 31/12/03 and 01/03/06 and 01/05/06 In Progress Not Fully Met) To provide lids for all waste bins in bathing and toilet facilities To increase the number of care staff on duty in the main house on afternoon / evening shifts to provide additional support and supervision regarding the service user with dementia who displays behaviour which challenges the service at these times The registered person must ensure that the Organisations nominated representative provides copies of Regulation 26 visit written reports to be
DS0000024952.V316119.R01.S.doc 01/12/06 9 YA29 23(2)(p) 13(4) 01/03/07 10 YA30 23(2) 13(4) 18(1)(a) 01/12/06 11 YA33 01/11/06 12 YA39 24 01/12/06 Halas Home Version 5.2 Page 33 held in the home 13 YA36 18(1)(c) 1) To ensure all care staff 01/12/06 consistently have regular recorded supervision meetings at least 6 times each year 2) To ensure supervision meetings cover - The homes philosophy and aims - Discussion, monitoring and review of work with individual service users - Support and professional guidance - Identification of individual training and development needs 3) Supervision records should identify actions, timescales and responsibilities To forward to the CSCI office, Halesowen documentary evidence of an asbestos risk assessment conducted by a competent person (Timescale of 01/03/06 Not Fully Met) To forward the copy of the current Landlords Gas Safety certificate, when received, to the CSCI office, Halesowen 14 YA42 23(4) 17(2) Sch 4 01/12/06 15 YA42 23(4) 17(2) Sch 4 01/01/07 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 YA7 Good Practice Recommendations That a person hygiene checklist is devised and used to
DS0000024952.V316119.R01.S.doc Version 5.2 Page 34 Halas Home 2 3 YA37 YA36 monitor that each person has received the level of personal support identified in their care plan It is strongly advised that she delegates this role to care staff to free up managerial time for monitoring, and developing the service That all accredited Dementia training is provided for all care staff, for example Yesterday, Today, Tomorrow Halas Home DS0000024952.V316119.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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