CARE HOME ADULTS 18-65
Halas Home Wassell Road Hasbury Halesowen West Midlands. B63 4JX Lead Inspector
Jean Edwards Unannounced 30 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 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 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 Mrs V Homer Care Home 41 Category(ies) of Learning disability (32), Learning disability over registration, with number 65 years of age (9) of places Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 31/01/05 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 three small, semi-detached, ex-council houses. These houses have frontages onto Wassall Road and Albrighton 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 long-term care and accommodation for up to thirty-seven people with a wide range of learning disabilities, whose ages range from 32 – 89 years, and one short-term respite placement. 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, 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. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection conducted by the Commission for Social Care Inspection (CSCI) visit took 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, administrator, members of staff and the majority of residents; and examination of records and case files. This visit also includes a brief tour of the premises. Over the past twelve months the organisation has had discussions with the CSCI and other agencies about the future direction of Halas Home, looking at other possibilities for some of the people to continue living at one of the satellite houses belonging to the home, possibly as tenants, with supported living arrangements. What the service does well:
The registered manager responded to the previous inspection report with a comprehensive action plan, which gave 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 residents are encouraged to treat Halas House as their own home and to be as independent as they wish. During the inspection, some of the people at home used the kitchen to make drinks and washed crockery without any prompting. Residents are able to make their own choices and are able to express their own wishes and pursue their own individual lifestyle. People are able to attend day activities provided by the Local Authority. The residents spoke enthusiastically about drama groups and their parts in a recent stars in your eyes competition. One person from Halas House had compared the show and another resident had won the competition, as Julie Andrews, singing edelweiss. The residents are really enthusiastic and excited about a show they are putting on at the home on 1 December 2005. The home supports residents to take holidays as they wish. A number of residents, small groups, have taken caravan holidays to Burnham on Sea. Other people have been on holiday to Lowestoft, though they commented it was a long way to travel. A group of residents are due to go to the Isle of Wight on the week following this inspection visit. In addition two residents are due to fly to Tenerife for football and athletics training in preparation for the Special Olympics, supported by the Special Olympics Charity.
Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 6 Residents are able to attend church if they wish and join in the life of the church. Some people go to the Catholic Church, others to the local United Reform Church. A range of topics is discussed at residents meetings, which take place on a regular basis, with views freely aired about the running of the home. The home was clean, tidy and homely. Residents each have their own bedroom, decorated and furnished to their own taste. Some people choose to have keys and are able to lock their bedrooms for privacy. Halas House has a stable group of staff; many 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 is a strong commitment to undertake training, which benefits the residents. There was a lot of friendly chatting between the members of staff and residents during the visit. During discussions the staff demonstrated a dedicated approach to their work; they clearly know the residents’ likes and dislikes and how to meet their needs. Residents commented I like all the staff and the staff help me to do things I enjoy. 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 home now provides a written account of residents decisions as a result of introductory visits on each persons case files. Each resident has a contract with the home, stating terms and conditions of residency. This document has been revised and updated according to the latest guidance. The home has put written guidelines and measures in place to minimise any known risks to residents. For example in relation to daily living activities such as making drinks in kitchens, going out alone, social activities, swimming, gateway club and so on. All residents have a written plan describing how their care and support will be provided. The care plans are regularly looked at and improved and each person or their representative now signs to show they know and understand about their care and support.
Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 7 The home has introduced a number of improvements to make the way residents medication is stored and used as safe as possible. The staff and residents are looking for alternative formats for the complaints procedure so that everyone, regardless of their ability is able to understand how to complain if they wish to. The home has done lots of work to improve policies and procedures, which protect vulnerable people from abuse or harm. All members of staff are being given training to recognise abusive situations and how to respond to them. They have been given a step-by-step guide to follow. The home has opened a new ground-floor wing attached to the main house, containing four new residents en suite bedrooms. Progress is continuing to provide bedroom door locks as a standard fitting whenever a bedroom becomes vacant. Staff job descriptions have been looked at and developed to make sure that they are linked to the residents needs and development. The home is continuing to make good progress to provide staff with training in equal opportunities, racism and disability awareness. Staff are now trained to look for and assess a range of risks in connection with the residents and the home environment. Improvements have been made to areas of health and safety, such as the lagging and security of the hot water tank in the linen cupboard. What they could do better:
To ensure that assessment information is signed and dated by the person undertaking the assessment; and that there is an indication that the resident and / or their representative has been actively involved To request a variation to the homes certificate of registration to seek agreement from the CSCI for admission of a wider / older age range of residents The home must make minor improvements to the records it keeps to demonstrate the care and support given to the residents. Written assessments and measures to minimise risks for specific areas of risk for individual residents must be put in place. These include risks of choking, using paper to block the toilets and displays of unacceptable behaviour. The organisation must make sure all staff receives appropriate training to be able to deal with challenging behaviour from residents. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 8 The premises do not entirely meet the needs of residents. For example, the programme of guarding radiators and exposed pipe work must be completed. The organisation must make sure that the internal environment is made safe for people living at the home and provide financial resources to complete all necessary health and safety improvements. Until all work is completed to guards all radiators and exposed pipe work, which pose risks to residents, written risk assessments must be put in place. There are a small number of improvements the home must make relating to health and safety. These include more detailed guidelines for the laundry and provision of supplies readily available disposable gloves and aprons in the laundry. 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 E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 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 standard(s) 1,2,3,4,5 Information about the running and performance of the home is made proactively available and residents are encouraged to make their views known. There is now an up to update contracts/terms and conditions of occupancy. This has the effect that residents and their advocates sufficient information regarding their rights and entitlements and any agreed restrictions. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed and reviewed to ensure that their needs will be met. EVIDENCE: During discussions residents are able to talk knowledgeably about the home and about the results of previous inspection visits. They feel they are able to voice opinions and views and influence improvements at the home. On examination of a sample of residents files the home has comprehensive assessment information and there was evidence of periodic reassessment, which is good practice. However the homes assessment documents are not signed and dated by the person undertaking the assessment. Discussions with staff and examination of documentation provide evidence that specialist services have been accessed, as needed. Throughout this visit the members of staff were seen to be communicating effectively with the residents. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 11 The sample of residents contracts/terms and conditions examined have been signed and dated. The home has obtained a copy of the Office of Fair Trading guidance and the contract/ terms and conditions have been updated accordingly. Revised versions are issued to new residents. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,8,9,10 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 could be further enhanced with more detail about more complex conditions. EVIDENCE: All residents have a care plan in place; the residents and / or their representatives are now signing these. During discussions with the residents who are happy to be part of the inspection process and who are able to communicate verbally, they confirm they have active involvement in developing and implementing their care plan for assistance and support. They are happy to share their information as part of this visit. There is evidence that proactive attempts have been made to involve other professionals and review care plans on a six monthly basis. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 13 There is evidence that areas of risk have been considered and discussed with each person, wherever possible. The home has a proactive approach to encourage each persons independence. Individual risk assessments include aspects relating to their personal safety, as people go out unaccompanied. However documentation and discussions with staff indicate that two new residents have risks relating to choking, blocking the toilet and some aspects of challenging behaviour. Examples are that one person had to go to hospital after choking on some food, fortunately there were no lasting ill effects. There is a staff accident record for an incident where a male resident hit her shoulder. This is explained as barging past rather than a deliberate act. There are currently no written risk assessments relating to these areas of risk. The Home has appropriate procedures in place for staff to follow in the event of a missing person or unauthorised absence. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,17 Links with the community are good; these support and enrich residents social and educational opportunities. The meals at Halas Home are good, with imaginative pictorial menus offering both choice and variety and catering for any special dietary needs. EVIDENCE: From assessment of residents case files and from discussions with groups of residents and staff there is evidence of structured activity programmes for some residents, whilst some residents prefer a more spontaneous approach to activities. A number of people continue to attend community based day opportunities for younger people organised by the local authority. One person has been able to continue his day care placement with a neighbouring Local authority, with transport provided by them. 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 chose to remain at home on the day of this visit. One of the newer male residents, with a visual impairment was happy to spend his time crocheting.
Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 15 The home has an activity planner and there are an improved number of trips especially at weekends. There have been trips to Cadbury World and the residents and staff particularly enjoy trips to the cinema at Merry Hill. A number of residents are encouraged and supported to fulfil their spiritual needs, attending local churches according to their faith or preference. One of the new male residents likes to be involved in the daily tasks around the home. He particularly enjoys helping the maintenance staff and gardener. Visitors and families are welcomed at the home and residents are supported and encouraged to maintain contact and visit families, where this is appropriate. New colourful pictorial menus have been devised with help from the residents. There is a varied range of nutritious food available in the kitchen, which is very well organised. Residents are complimentary about the food, saying there is always plenty to eat and lots to choose from. Fresh fruit is readily available in the open kitchen area. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Personal support in this home is offered in such a way as to promote and protect residents privacy dignity and independence. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure each persons medication needs are met. EVIDENCE: Residents are provided support and assistance for their personal care according to their individual preference. During discussions the member of staff gave thoughtful examples of how residents’ privacy, dignity and independence is maintained. The home has a key worker system, which enhances this aspect of care and each persons choice of how and when their personal care is supported. In addition the home has now been able to recruit more male carers, which helps to offer residents a choice of gender of staff assisting with their personal care. There is evidence of 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. A senior member of staff is to be part of a work group, lead by a nursing colleague to consider appropriate ways to educate adults to examine their bodies for abnormalities.
Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 17 The home has comprehensive medication policies and procedures and there was evidence that existing staff administering medication have received accredited medication training. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 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 being implemented in order to provide residents with sufficient safeguards from abuse. EVIDENCE: There are three complaints recorded in the home’s complaints log since the last inspection visit in January 2005. One relates to a complaint from a resident about a member of staff, which has been resolved. The others relate to issues raised by staff about incidents with residents, such as unacceptable behaviour. These are not appropriate to the complaints log, which is for complaints about the home or service. Incidents relating to residents behaviour need to be logged as incidents and be reviewed along with risk assessments. The residents spoken to stated that they felt that they could voice any concerns either directly with the manager or staff. Discussions with staff indicate that they are aware of the homes procedures and the local authority multidisciplinary procedure for the protection of vulnerable adults. Staff have been provided with appropriate levels of training to ensure that they are aware of and are able to respond appropriately situations, which require them to take action with the protection of vulnerable people. However the home still has to source and provide staff with training to deal with challenging and aggressive behaviour. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,26,29,30 The standard of the interior décor within this home is generally good with evidence of improvement through maintenance and future planning, providing a homely and comfortable environment for residents. The manager has 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 41 adults with learning disabilities. The premises currently comprise the large three-storey house with two extended ground floor wings and three (3-bedded) satellite houses. One house is being considered for deregistration and a change to supported living for the three people living there. A brief tour of the premises demonstrated that the houses are clean, homely and comfortable. Although the main house stands in its own grounds, all properties blend well with the local community and offer good access to local amenities. The fixtures, fittings and furnishings are good quality and domestic in character. There is ongoing maintenance to the interiors and exterior of properties.
Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 20 Each resident has an attractively decorated bedroom. There was ample evidence that they can personalise their rooms according to their individual preferences. The people consulted confirmed that they are able to make choices about both their personal space and the communal living accommodation. There are completed inventories of residents’ personal possessions, including furniture brought into the home on each person’s file. Some residents have lockable space and a few hold keys to their bedrooms. There is generally a high standard of cleanliness throughout the home, with everyone involved in domestic tasks. The manager has obtained infection control guidelines from Dudley Public Health / Infection Control and has devised policies and procedures to ensure that should the need arise everyone follows appropriate infection control measures. However during the tour of the laundry, which is in a separate building in the grounds, it is noted that the procedure needs expansion and there is no readily available supply of disposable gloves and aprons. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34 The home has a generally stable, enthusiastic, well-motivated staff team and though residents receive consistent assistance and support to develop their potential. EVIDENCE: Halas Home has a stable staff team of 52 people including the Registered Manager. There are 34 care staff, including seniors, 14 ancillary staff an administrator and a finance officer. There have been 5 resignations since the inspection in January 2005, through retirement, promotion, change of career and one dismissal. Though the care staff team is predominantly female, it represents a wide age range and additional male carers have been recruited. Comprehensive staff rotas demonstrate that adequate staffing levels are provided to meet residents needs and aspirations. The organisation has completed the development of staff job descriptions to ensure that they are linked to residents care plans and their goals. Members of staff consulted have demonstrated that they are aware of the values and aims, policies and procedures of the home. There is evidence that staff are knowledgeable and have positive relationships with residents and families. The sample of staff files assessed at this visit there is ample evidence of continued commendable recruitment practice, with very well ordered staff files and comprehensive documentation. There are signed and dated copies of
Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 22 interview notes on staff files, which is good practice. There is appropriate POVA/CRB clearance and all documentation required in Regulation 17, Schedules 2 and 4 easily found on staff files, which are held securely in the office in compliance with the Data Protection Act 1998. There is documentary evidence that each person is issued with their individual copy of the General Social Care Council (GSCC) code of practice and conduct and supervision sessions ensure all staff are familiarised with the contents. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,41,42 The registered manager is supported well by her senior staff in providing clear leadership throughout the home with staff demonstrating an awareness of their role and responsibilities. The systems for resident consultation at Halas House are good with a variety of evidence that indicates that residents’ views are both sought and acted upon. EVIDENCE: Mrs Vicki Homer, the Registered Manager has been in post at Halas Home for twenty-one years; she has a number of years of valuable experience in developing and running services. She continues to update her professional development and she attends and participates in workshops, conferences and forums, for example the Learning Disability Partnership Board, and Provider Forum. The planned registration of a new manager, who has undertaken the Registered Manager’s Award, has been temporarily deferred due to the persons domestic circumstances. There are good arrangements in place to ensure that residents are consulted about the day-to-day running of the home. For example, there are regular
Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 24 (and recorded) residents meetings, with a wide range of topics discussed. There are arrangements for residents feedback questionnaires to be regularly used and collated. A sample of fire safety and maintenance service records has been examined and they are satisfactory. There are 14-recorded accidents involving residents and 15 accidents involving staff and visitors since the inspection visit in January 2005, with evidence that regular analysis of accidents takes place. Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 3 3 3 Standard No 22 23
ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 x 3 2 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x 3 2 x 2 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 x x 4 Standard No 31 32 33 34 35 36 Score 3 x 3 4 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Halas Home Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 2 2 x E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5(2)(3) Requirement To progress the production of the service user guide in formats suitable for service users (Timescale of 31/12/04 Not Fully Met) To ensure that assessment information is signed and dated by the person undertaking the assessment; and that there is an indication that the resident and / or their representative has been actively involved To ensure that the Home’s certificate of registration is changed to accurately reflect current registration details (Timescale of 31/12/04 Not Fully Met) To request a variation to the homes certificate of registration to seek agreement from the CSCI for admission of a wider / older age range of residents To expand, develop and agree with each service user an individual 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 Timescale for action 01/01/06 2. YA2 14(1) 01/11/05 3. YA3 CSA. S 01/11/05 4. YA3 CSA. S 01/11/05 5. YA6 15(1) 01/12/05 Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 27 6. YA7 15(1)(2) 7. YA7 20(1) 8. YA9 13(4) 9. YA9 13(4) 10. YA9 13(4) 11. YA16 12(1) 13(1) 12. YA21 12(1) 13(1) changing needs, aspirations and achieve goals, and be reviewed six monthly (Timescale of 31/12/04 Not Fully Met) To provide evidence in the 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 Not Fully Met) To review all Service Users 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 Not Fully Met) 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 Not Fully Met) To devise and implement written risk assessments for WB relating to risks of choking and using paper to block the toilet To devise and implement a written risk assessment and behaviour monitoring charts for LC relating to challenging behaviour 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 Not Fully Met) To instigate sensitive discussions to ascertain the final wishes of 01/12/05 01/12/05 01/11/05 01/11/05 01/11/05 01/12/05 01/12/05
Page 28 Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 13. YA23 13(6)(7) 14. YA29 23(2)(p) 13(4) 15. YA29 23(2)(p) 13(4) 16 (2) (l) 16. YA26 17. YA30 16 (2) (j) 18. YA42 13(3) Service Users and/or their families, documenting decisions in their plans. (Timescale of 31/12/04 Not Fully Met) To ensure that all staff receive appropriate training to raise awareness of challenging behaviour and dealing with violence and aggression. (Timescale of 31/12/04 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 31/12/03 Not Fully Met) To devise and implement written risk assessments for all radiators without guards and exposed pipe work accessible to residents To progress the provision of lockable space in service users bedrooms on a prioritised basis (Timescale of 30/06/05 Not Fully Met) To seek advice from Environmental Services and/or the Infection Control Nurse regarding the lack of and washing facilities in the male toilets on the first-floor (Timescale of 31/03/05 Not Fully Met) 1) To review and expand the laundry procedures 2) To ensure that there are supplies of disposable gloves and aprons readily available in the laundry 01/12/05 01/03/06 01/12/05 01/12/05 01/12/05 1/11/05 Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA19 Good Practice Recommendations That discussions should take place to ensure that service users understand the need to regularly check themselves for any abnormal / unusual changes in their bodies. – In progress That alternative formats for the complaints procedure is developed, which are suitable for service users capabilities – In progress That all staff receive appropriate awareness training in Equal opportunities (delivered 8/6/04), Racism and Disability awareness – In progress That staff awareness of healthcare needs, checks and monitoring, should be documented on training records/plan. – In progress That applicable policies be developed into formats, such as pictorial /audio/ video, which are suitable to service users capabilities, examples: service users write to access their records, complaints procedure, fire procedure etc. - In Progress 2. 3. 4. 5. YA22 YA35 YA35 YA40 Halas Home E55 S24952 Halas Home V248367 Stage 4 120905 E55.doc Version 1.40 Page 30 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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