CARE HOME ADULTS 18-65
Halas Home Wassell Road Hasbury Halesowen West Midlands B63 4JX Lead Inspector
Mrs Jean Edwards Unannounced Inspection 20th February 2006 09:30 Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 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.V284094.R01.S.doc Version 5.1 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.V284094.R01.S.doc Version 5.1 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 info@halashomes.co.uk 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.V284094.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Includes 2 satellite houses at 64 and 66 Wassall 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 12/09/05 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 32 - 89 years. The second floor of the main building has been converted to provide two semi-independent 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, twentyeight 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. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection conducted by an Inspector from the Commission for Social Care Inspection (CSCI) visit has taken place over one weekday. The purpose of this visit is to assess progress towards meeting the national minimum standards for younger adults and assess progress towards improvements needed at previous inspection visits. Inspection methods used to make judgements and obtain evidence include: discussions with the registered manager, general manager, administrator, members of staff and the majority of residents; and examination of records and case files. This visit has also included a brief tour of the premises. On 1 February 2006 following consultations and agreements with the CSCI and other agencies the organisation has deregistered one of the satellite houses belonging to the home, and is now providing supported living arrangements for some of the people to continue living at 19 Albrighton Road. What the service does well:
The registered manager and organisation responded to the previous inspection report with a comprehensive action plan, giving dates for the required improvements to be put into place. The registered manager is committed to making sure that improvements happen, where she has the authority to make decisions. The majority of residents are able to make their own choices and are able to express preferences and pursue their own individual lifestyles. Some people are able to attend day activities provided by the Local Authority. Other are encouraged to attend day time activities provided by staff from Halas Homes in a separate building in the grounds. They are currently making chicks and daffodils using paper products and painting materials. Residents also have hobbies and interests outside the home, such as going to the cinema. A number of people recently enjoyed a trip to see Narnia. Some people enjoyed visits to the hairdressers or reflexology treatments in Stourbridge. There are also organised trips to places such as Cadburys world. The residents are supported to go away for holidays according to their personal preference. Holidays are currently being booked at a recommended hotel in Blackpool for small groups of residents and staff in June and November 2006. One person says she is pleased that she can choose her companion to accompany her on her holiday in June. 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
Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 6 local United Reform Church, travelling by their preferred mode of transport. Whilst some use the Ring & Ride service one person likes to travel by taxi. 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 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. There is a redecorating and renewal programme taking place, with seven bedrooms completed. One person does not like objects in his bedroom and the decorator has painted a particularly impressive porthole mural depicting an undersea scene on the bedroom wall. There are also new comfortable reclining chairs in the main residents lounge. 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 in trips away from the home. There continues to be strong commitment to undertake training, which benefits the residents. There was a lot of friendly banter between the members of staff and residents during the visit. During discussions the staff continue to demonstrate a dedicated approach to their work; they clearly know the residents’ likes and dislikes and how to meet their needs. Residents have said how helpful the staff are to have spoken about staff they particularly like. 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 staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection?
The organisation has produced copies of the service user guide in alternative formats, using pictures and symbols suitable for residents and other people unable to easily understand written information. The home has made improvements to make sure that assessment information is now signed and dated by the people are involved in collecting information and there is now clear indication that the resident and / or their representative has been actively involved. These processes are now linked to the Primary Care Trust health screening initiative, which means that each person has a health passport. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 7 There has been communication between the organisation and CSCI to make sure that the Homes Certificate of Registration has been changed to accurately reflect current registration details relating to the numbers and ages of residents able to live at Halas Homes. The number of residents living at the satellite houses has been reduced from six to five, giving residents extra space and creating an improved sleep in facility for staff. In addition residents with the potential to progress to live in supported housing have been identified and will be given any help that is needed to develop their abilities. The home has improved the way in which risks and control measures are recorded relating to individual residents, for example risks of choking or misusing facilities such as blocking the toilets with paper. The organisation has made excellent progress to make sure that all staff have received appropriate training to raise awareness of challenging behaviour and to be able to deal with it safely. The registered manager has made progress to instigate sensitive discussions to find out about the final wishes of residents and/or their families, to be able to record decisions in each persons plan. This is a positive process, which can avoid painful discussions at latter stages of someones life. Good progress has been made to start discussions with residents to help them 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. In addition staff awareness of healthcare needs, checks and monitoring, is now included on the training plan and records of training received. The local pharmacist has provided additional training for staff and is planning to meet 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 organisation has been successful in developing alternative formats for the complaints procedure is, which help residents understand and be able to use the complaints process if they need to. The organisation has commissioned three new boilers to be installed in the main house together with a new central heating system. This is due to take place over the two weeks following this inspection visit. The process will also incorporate new low surface temperature radiators, which will reduce any risk of accidental burns. The organisation is considering possible changes to smaller bedrooms in the main house to introduce improved facilities. The registered manager has made a number of improvements relating to health and safety, including a directive for alternative hand washing in an existing male toilet without hand washing facilities, a new laundry procedure and readily available disposable gloves and aprons in the laundry area. The
Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 8 organisation is also at an early stage of exploring options for new and improved laundry facilities for the home. The organisation continues to build on its strong commitment to staff training; recently 4 members of staff have attained NVQ level 2. The home has obtained funding for NVQ training for staff to attend Dudley College and two members of staff are due to register as candidates. The organisation has provided appropriate awareness training in Equal opportunities, Racism and Disability awareness for all staff. The organisation is continuing the commendable progress to make sure that all applicable policies are developed into formats, such as pictorial /audio/ video, which are more suitable to residents capabilities, examples are rights to access records, complaints procedure and fire procedure. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 9 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.V284094.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards have been assessed at the inspection visit on 11 July 2005 and were satisfactory. EVIDENCE: Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily support each persons needs. This will be further enhanced with more detail about the more complex conditions. EVIDENCE: All residents have a care plan in place, with evidence that the residents and / or their representatives are involved and have agreed by signing the plan. During discussions with the residents who are able to communicate verbally, there is confirmation of their active involvement in developing and implementing a care plan for assistance and support. People have been happy and keen to share their information as part of this visit. There is evidence of improvements to the risk assessments for two residents with risks relating to choking, blocking the toilet and some aspects of challenging behaviour. However daily notes indicate some incidents of behaviour from one person, which could be considered to be challenging. The use of behaviour monitoring charts would be beneficial in identifying trends and triggers and improved preventative strategies.
Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 12 The organisation needs to continue progress to meet the previous requirement to provide evidence in the service user plan of discussions and decisions made with each person about lifestyle choices, particularly relating to the management of finances and any limitations on choice. The home has a comprehensive computerised system for managing residents finances. The centralised system remains unchanged, with one communal account held by the organisation in the name of Halas Homes on behalf of all residents. There are no residents currently accommodated to manage any part of their own financial affairs. There is a weekly accounting system for tracing income and outgoings for each person. Actual monies are paid to each person on the basis of what they need one wish to spend. All financial records are held communally and there are a number of communal receipts. The system means that individual residents or relatives cannot have a printed statement or view their individual transactions without a considerable amount of work to extrapolate the information. The organisation must ensure all records (including financial records fully comply with the Data Protection Act 1998). There is no suggestion that the system does not protect residents finances and there is evidence of audits by external auditors. However the system does not promote independence or develop money management skills for those residents have capacity to understand and consent and who are capable of developing. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 15, 16 Links with families, friends and the local community are good, enriching residents opportunities for social stimulation. EVIDENCE: During discussions with groups of residents and staff there is evidence that the structured activity programmes continue to work well for some residents, whilst other residents prefer a more spontaneous approach. A number of people continue to attend community based day opportunities for younger people organised by the local authority. Some of the older residents described how they enjoy regular attendance at a day centre for older people provided by the local authority, although they were a number of grumbles about the reliability of transport arrangements, also provided by the local authority. One person continues with his day care placement that a neighbouring Local authority, with transport provided by them. One male resident, with a visual impairment still happily spends his time crocheting. The staff encourage residents who choose to stay at home to participate in activities provided by staff from the home in a building in the grounds.
Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 14 Residents have indicated a type of activities they wish to have, ranging from music to arts and crafts. The outcomes of their efforts during the day of the visit are artistic chicks and daffodils in various stages of creation ready for Easter. One of the male residents continues to enjoy the involvement in the daily tasks around the home, indicating to the inspector when she was in his way whilst he was sweeping. He particularly enjoys helping the maintenance staff and gardener. A number of residents continue to be supported to fulfil their spiritual needs, attending local churches according to their faith or preference. Staff and residents are in the process of planning holidays throughout the coming year. Some people prefer to go in small groups and there is a wish to try out a hotel in Blackpool, which has been recommended. Some residents will be going away on organised holidays associated with their activities, such as the Special Olympics. Visitors and families are welcomed at the home and residents are supported and encouraged to maintain contact and visit families, where this is appropriate. Some residents go to stay with relatives, for example for weekends. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21 The majority of these standards have been assessed at the inspection visit on 11 July 2005 and were satisfactory. Personal support in this home is offered in such a way as to promote and protect residents privacy dignity and independence. EVIDENCE: From the sample of residents case files and discussions there is evidence of continued good multi-disciplinary working. Residents are offered appropriate access to health care services and screening processes, with agreements, outcomes or refusals recorded in each persons case file. Staff are working with nursing colleagues to implement health passports for each resident covering all aspects of well being. The home has been proactive relating to appropriate ways to educate residents to 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 being discussed at residents meetings and with residents on an individual basis. Discussions have taken place during the visit about the homes concerns about one resident with an unstable diabetic condition. Advice has been given that
Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 16 further discussions should be held with the diabetic nurse specialist and / or the community dietician to assist with stabilising RWs blood sugar levels. The home has policies and procedures relating to dying and death, and staff are familiarised with any revised guidance. There is evidence from discussions about the care of the residents that members of staff understand how to sensitively care for and support each person and their family. The home is making progress to instigate sensitive discussions to ascertain the final wishes of residents and/or their families, documenting decisions in their plans. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home has a satisfactory complaints system with evidence that residents feel that their views are listened to and acted upon. Policies, procedures, guidance and staff training are implemented to provide residents with sufficient safeguards from abuse. EVIDENCE: There have been no complaints recorded in the home’s complaints log since the last inspection visit in September 2005. The organisation has now developed alternative formats for the complaints procedure, which are more suitable for residents capabilities. The residents consulted state 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. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26, 29 The majority of these standards have been assessed at the inspection visit on 12 September 2005 and were generally satisfactory. The interior of the home presents as a homely and comfortable environment for residents and the exterior of the premises are maintained to high standards. The manager and committee have a good understanding of the areas where the home needs to improve, and there is proactive planning in place indicating how this improvement is going to be resourced and managed. EVIDENCE: Halas Home currently provides accommodation for up to 37 adults with learning disabilities. The premises currently comprise the large three-storey house with two extended ground floor wings and two (3-bedded) satellite houses. A third house was deregistered on 1 February 2006 and the three people now live supported living arrangements. During a 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 refurbishments with new reclining chairs in the lounge of the main house, which residents use with obvious enjoyment and comfort. The decorator has recently completed the refurbishment and redecoration of 7 bedrooms in the
Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 19 main house. One bedroom has a particularly attractive undersea mural. There are plans to refresh the dining room. There is evidence of 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. Advice has been sought from the Infection Control Nurse regarding the lack of and washing facilities in the male toilets on the first-floor; the advice to devise a sign indicating the hand-washing facilities in the next room has been put in place with good results. The homes laundry continues to be well organised and achieves good standards of infection control. The registered manager has implemented an expanded laundry procedure and measures have been put in place to ensure that there are supplies of disposable gloves and aprons readily available in the laundry at all times. The organisation is considering plans to expand and redesign the laundry area. Throughout the home good standards of cleanliness continue to be maintained and there have been no discernable malodours during this visit. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35,36 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. EVIDENCE: Assessment of staffing rotas at this visit demonstrates that the home continues to maintain satisfactory staffing levels. The registered manager reviews staffing levels on a regular basis, taking account of the occupancy and dependency levels of residents accommodated, this is good practice. A copy of staffing rotas has been given to the Inspector during this visit. Halas Home has a stable staff team. There have been 4 resignations since the inspection in September 2005, for valid reasons such as promotion, change of career or domestic commitments. There is currently a vacancy for a domestic post, which is being advertised as 2 x part time posts and 2 vacancies for care assistants, with interviews due to take place on 23 February 2006. Discussions with members of demonstrate that they are aware of the values policies and procedures of the home. There is evidence that staff are knowledgeable and have positive relationships with residents and families. All
Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 21 staff have job descriptions, which are linked to residents care plans and their goals. A random sample of staff files assessed at this visit continues to demonstrate 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 has provided all staff with appropriate training to raise awareness of challenging behaviour and skills to respond to behaviours from residents, which may challenge them or other people. Training needs are identified through the homes structured supervision system, which ensures all care staff participate in a supervision meeting every 6-8 weeks. All staff also have an annual appraisal. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 40, 41,42 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. EVIDENCE: Mrs Vicki Homer, who was the Registered Manager at Halas Homes for more than twenty-one years, has moved to a more strategic role in the organisation, though she retains a strong involvement with the home. Mrs Kathryn Rudge has now successfully completed the registration process with the CSCI and is undertaking the role of Registered Manager. She has a number of years of valuable experience in assisting the development and running the service provided by Halas Homes. She continues to update her professional development and she attends and participates in workshops, and has undertaken the Registered Manager’s Award. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 23 Residents and staff consulted feel that the management team of the home are approachable, supportive and people feel that they are able to air their views in an open manner. The organisation has made excellent progress with the development of applicable policies into formats, such as pictorial /audio/ video, which are more suitable to residents capabilities. A sample of fire safety and maintenance service records examined is generally satisfactory. However a small number of improvements are needed. There are a small number of gaps in records of the weekly fire alarm checks, which must be conducted and recorded consistently and there is currently no documentary evidence of an asbestos risk assessment conducted by a competent person. There are 9-recorded accidents involving residents and 6 accidents involving staff and visitors since the inspection visit in September 2005. However the regular documented accident analysis (last documented 25/10/05) must be resumed. Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 24 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 3 27 X 28 X 29 2 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X 3 3 X X 3 2 2 X Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 25 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 Timescale for action 01/04/06 2. YA7 15(1)(2) 3. YA7 20(1) 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 Not Fully Met though improved) To provide evidence in the 01/04/06 service user plan of discussions and decisions made with each person about lifestyle choices, management of finances and any limitations on choice. (Timescale of 31/12/04 and 01/12/05 Not Fully Met) To review all Service Users 01/04/06 finances, which are held by the Organisation, with proposals for compliance with Regulation 20(1) to be forwarded to the CSCI satellite Office - Halesowen for consideration. (Timescale of 31/12/04 and 01/12/05
DS0000024952.V284094.R01.S.doc Version 5.1 Halas Home Page 26 Not Fully Met) 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 multiagency 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) To expand and develop documented risk assessments and risk management strategies with the service users, especially relating to their personal safety, activities etc. to be held on their individual plans. (Timescale of 31/12/04 and 01/11/05 Not Fully Met) To implement behaviour monitoring charts for any resident presenting behaviours which challenge the service or other people using the service (e.g. MC) To ensure that the daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions, e.g. smoking, medication, are agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary) (Timescale of 31/12/04 and 01/12/05 Not Fully Met) To complete work to ensure that all radiators and exposed pipe work is guarded or has guaranteed low surface temperatures. (Timescale of
DS0000024952.V284094.R01.S.doc 01/05/06 5. YA9 13(4) 01/03/06 6. YA9 13(4) 01/03/06 7. YA16 12(1) 13(1) 01/04/06 8. YA29 23(2)(p) 13(4) 01/05/06 Halas Home Version 5.1 Page 27 9. YA42 23(4) 17(2) Sch 4 31/12/03 and 01/03/06 Not Fully Met) 1) To ensure the weekly fire alarm checks are conducted and recorded consistently 2) To resume the regular documented accident analysis (last documented 25/10/05) 3) To forward documentary evidence of an asbestos risk assessment conducted by a competent person 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA19 Good Practice Recommendations That further discussions are held with the diabetic nurse specialist and / or the community dietician to assist with stabilising RW blood sugar levels Halas Home DS0000024952.V284094.R01.S.doc Version 5.1 Page 28 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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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