Inspection on 21/01/08 for Hillcrest (Stourbridge)

This inspection was carried out on 21st January 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hillcrest (Stourbridge) 40 Perrins Lane Wollescote Stourbridge West Midlands DY9 8XP Lead Inspector Mrs Jean Edwards Unannounced Inspection 21st January 2008 07:50 Hillcrest (Stourbridge) DS0000069595.V357555.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 Hillcrest (Stourbridge) DS0000069595.V357555.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. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcrest (Stourbridge) Address 40 Perrins Lane Wollescote Stourbridge West Midlands DY9 8XP 01384 823050 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) Select Health Care (2006) Limited Vacant post Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Learning Disability (LD 7) The maximum number of service users to be accommodated is 7. 2. Date of last inspection 10th May 2007 Brief Description of the Service: Hillcrest is a traditional house, which has been converted to provide accommodation for 7 younger adults with learning disabilities. The home is situated in a quiet residential area in Wollescote and blends well into surrounding properties. All rooms are single and one room has an en-suite facility. There is a small parking area at the front of the building. There is a patio area on the ground floor and a garden area on the lower ground floor to the rear of the property. Bedrooms are situated in the lower area and first floor of the house. There is no lift access for service users. There are lounge and dining room facilities on the ground floor. The home currently has limited bathing and toilet facilities. The Home provides care for people with a range of learning disabilities who may also have challenging behaviour. A statement of purpose and service user guide is available to inform residents of their entitlements. Information regarding fee levels is not currently included in the published statement of purpose and service user guide. There are additional charges for residents, which include hairdressing, chiropody, toiletries and holidays. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second unannounced key inspection visit for 2007 - 8, undertaken by two inspectors from the Commission for Social Care Inspection (CSCI). This means the home has not been given prior notice of the inspection visit. The inspectors have spent one weekday at the home. All Key National Minimum Standards have been assessed at this visit. The range of inspection methods to obtain evidence and make judgements includes: discussions with the acting manager and staff on duty during the visit, discussions with two residents, observations of residents without verbal communications and examination of a number of records. Other information was gathered before this inspection visit from the homes Annual Quality Assurance Assessment (AQAA), notification of incidents, accidents and events submitted to the CSCI. The CSCI sent out service user surveys, relatives surveys, health care professional and staff surveys. An analysis of the returned survey forms from service users, and responses from relatives, staff and health care professionals is contained throughout this report. There are currently four residents living at Hillcrest, there are three vacancies and the home has admitted one new resident since the key inspection in May 2007. Formal interviews with residents are not always appropriate therefore other methods such as informal chats, observations of body language, eye contact, gestures, interactions between staff and residents have been used. There has been a tour of the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents’ bedrooms, with their permission, where possible. Since the home was last inspected the CSCI has reviewed its procedures regarding issuing Requirements and Recommendations. As a result many of the Requirements previously identified have now been altered to Recommendations. The quality rating for this service is zero stars. This means the people who use this service experience poor quality outcomes. What the service does well: We received two surveys completed by relatives of people living at the home. Residents are supported to maintain good contact with their families wherever this is possible. One person has visited their family during this inspection visit. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 6 The home has a large, bright kitchen that is clean and tidy. There is a ready supply of disposable aprons, liquid soap and paper towels in place and staff using these, which means there is good infection control. We have seen good rapport between staff and residents during this inspection. During discussions with staff on duty they show a dedicated and committed approach. The staff have answered questions in an open and honest manner and show they know about residents’ likes and dislikes and try to meet their needs. Staff either hold or are in the process of obtaining a National Vocational Qualification (NVQ). The home employs a total of eleven staff and the majority will have completed an NVQ II or above or are working to obtain the qualification. We were shown full assistance during the visit and would like to thank everyone for the assistance and hospitality. What has improved since the last inspection? The home has a new manager, recently in post, who is committed to improve standards of care and support and independence of residents wherever possible. Comments from healthcare professional surveys are, have been involved with Hillcrest for many years. Historically has been very poor service with very high staff turnover, especially managers. New manager very recently appointed appears to have much more positive approach, and willing to work with other agencies, but will need a lot of internal & external support and the motivation & commitment of the new manager is impressive & refreshing. She is making good efforts to rebuild the reputation and records within Hillcrest. The way the home plans each persons care shows signs of improvement with more detail but more work is needed and areas needing better and specific information have been discussed. The results from healthcare professional surveys are generally positive about the improvements this home is making to meet residents healthcare needs, which indicates better relationships between the staff and health care professionals. Comments are, They appear to be making contact with relevant agencies re health care, again the main work at the moment relates to setting baselines for people that were not evident or there with the previous organisation and I think this is something that is getting better, people are slowly beginning to be acknowledged as individuals with different outlooks and interests. This has contributed to increased quality of life and less frequent challenging behaviour for the people I support. The home now has clear written guidance as to when to give residents medication prescribed to be given ‘when required’ and a community nurse states, my only insight in this area has been the use of PRN medication, staff previously did not give it early enough. Staff now seem to recognise that given Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 7 correctly it can be a useful tool to supporting someone to relax, also protocols for PRN have been written. In discussions staff say that the new organisation provides more training opportunities, a comment from the staff surveys about what the homes does well states, Provides training and support” and comments from healthcare professionals are, I think what this staff team needs is a consistent manager who can mentor and support staff to work in a more person centred way, some staff have attended training events led by I.S.T. looking at challenging behaviour and The quality of individual needs being met (I think they are trying but are hampered by current resources). We are told the recent training for the newest member of staff has been cancelled and we have advised that the training programme must be continued. The organisation has taken action to meet the legal requirements issued by the West Midland Fire Service. What they could do better: A number of improvements stated to have taken place by the care provider, could not be fully validated during this inspection, for example not all new person centred care records are completed. The homes Annual Quality Assurance Assessments (AQAA) submitted to the CSCI should contain accurate information and better detail of the supporting evidence of what the home does well and how the improvements have been made. Information about the services the home provides needs to be revised, updated and produced in easy to read and alternative formats, suited to each persons level of understanding. There are has admission procedures to make sure prospective residents needs are known and assessed before they move into the home. Usually people are invited to visit the home and stay for short periods before deciding to live there. These processes were not followed when the most recent resident moved to the home. Staff confirmed that when the person moved into the home they did not know or understand their particular needs. This is means that the person may not receive the care and support they need and it also may result in avoidable disruption for people who already live at the home. Any future admissions to the home must be planned more thoroughly. The way each person’s care and support is planned does not show that the resident and their individual needs and wishes is at the centre of the process. Person centred plans have still not been completed and there is little to show that the resident and or their supporters are involved. The registered persons must provide staff with training so that they understand how support can be provided to each resident as an individual. Person centred care plans must be simplified and completed with accurate information so that each person can have all of their needs and wishes met in the way they prefer. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 8 We found that residents unable to speak or use other communication methods are not really able to express any views or opinions. The registered persons must put in place communication plans, which offer each person a way of expressing themselves, so that their rights are not ignored. The way that the home currently assesses risks to residents is too general and does not take account of each person’s individual and specific needs or abilities. For example one person is known to have obsessive behaviour and may try to run away and can also become aggressive, overturning furniture if they feel thwarted but the home does not have written measures to control or minimise the risks to this person or other residents and staff. The registered persons must have clear written guidelines to identify and minimise all known risks to safeguard everyone at the home. There are many examples of decisions being made, which do not show how the individual resident’s have been involved. The decisions range from preferred routines for getting up and going to bed, mealtimes, nighttime checks, changes to the interior of the home and changes of GP. A comment from the CSCI healthcare professionals states, One concern is that Hillcrest (and the organisation Select Healthcare) have registered all the service users with the same GP for all their homes. This does not seem to match with the values of PCP. The registered persons must make sure the management and staff are familiar with The Mental Capacity Act 2005 and follow its principles to show how people who are not capable of decision making are supported. There are not enough staff on duty to allow residents to participate in individual activities, which take account of their individual needs and preferences. A comment from the Healthcare professional surveys states, Due to staffing restrictions, service users seem to have to go out in groups or all together - I would like to see more opportunities for more 1-to-1 to be incorporated within daily life. I have discussed this with the current home manager and she has stated this will be reviewed and a comment from the relatives surveys confirms this view with the comment, when possible staff do take X out shopping etc., X likes to get out more, this is impossible due to lack of staff.” The registered persons must make sure that there is a system in place to accurately find out about each resident’s preferred activities and that staffing levels are sufficient to provide support to resident’s participation, and promote a person centred approach to lifestyles. Food stocks at the home are limited and the residents are not always given a choice. There is not sufficient information available on resident’s individual records to show that they receive a nutritious diet to meet their needs. The registered person must make sure that new menus are assessed by a community dietician for adequate nutrition, that menus are produced in pictorial formats to assist resident’s to make real choices and each person’s food (and fluid) intake is recorded, as necessary. Residents should be given the opportunity to be involved in food shopping, as this is currently not taking place. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 9 The way the home stores and manages residents medication requires some immediate improvements, to safeguard the residents as much as possible. The layout of the home and changes, such as decreasing the number of toilets affects not only freedom of movement but opportunities for residents to be as independent as possible and participate in developing life skills. The registered persons must make sure residents; their advocates and the CSCI are involved in significant changes to the interior of the home. Additionally there are serious concerns about the safety in some areas of the home, such as the lack of window restrictors on the first floor, and the damaged and raised flooring in two toilets, which pose a tripping hazard. There are also large radiators, which are excessively hot to touch and could cause burns to residents, without sufficient awareness. We have issued immediate requirement forms to the registered persons to take action to rectify these matters and reduce the risks of serious harm to the residents. The maintenance programme for the home has not been continued, this means the residents do not have a pleasant and safe environment and progress must be resumed with identified timescales for completion. The relatives’ surveys contain the comment about what the home could do better, make the home more homely not enough furniture in living room. But have said they are getting some, still waiting after 5 months. There must be enough well trained and skilled staff to meet residents’ care and social needs at all times. A comment from the relatives survey about what the home could do better states, by employing more staff and training them to the homes needs and this is also reflected in comments from the healthcare professional surveys, from my observations, they are trying to build up the quality of the service, but do not appear to have enough staff on duty. However on a basic level they do appear to take into account peoples needs and are attempting to meet them. As we highlighted at the previous inspection staff still require specialist training. Staff cannot currently demonstrate a good working knowledge of the principles of person centred approaches. Progress must be made to provide staff training in other areas including nutritional awareness, risk management, equal opportunities, LDAF and the Mental Capacity Act to ensure staff are suitably qualified for their positions and to support residents. The registered persons must also make sure that the home demonstrates a rigorous approach when recruiting staff, recording reasons for any gaps in any previous employment and accepting only authenticated references. Staff must also receive regular, formal supervision so that they are developed and supported to assist residents to have satisfying, fulfilling lifestyles. The registered persons must improve the quality assurance arrangements, and use formal surveys to seek the views of professional colleagues about the performance of the home and support for residents. Some records at the home have improved, however the acting manager must put in place additional arrangements to monitor all records, especially those Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 10 relating to residents personal, health care and health and safety, and show what action has been taken where records are not satisfactory or missing. During the inspection we observed a fire door wedged open and there is written evidence that a resident’s door is propped open during the night-time. We also found that two of the permanent staff have not participated in a fire drill within the last 6 months. This is of concern as both work during the night when reduced staffing levels and the lack of training poses greater risk to residents in the event of a fire. 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. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 11 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 Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 12 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this outcome area is poor The homes’ statement of purpose and service user guide is not entirely up to date or in appropriate formats suited to residents and their supporters meaning information about Hillcrest is not always readily accessible. Although the home has processes in place to assure residents have their needs assessed by competent persons prior to moving into the home, it is difficult to determine how the resident or staff participated in this assessment process, due to lack of documentation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which the acting manager states has probably been written by the Human Resources Manager at head office. The service user guide is written in larger print and is dated HJW March 2007. Despite the recommendations made at the inspection visit in May 2007, there is no evidence that the documents have been produced in alternative formats. There has not been any involvement of the acting manager or service users living at Hillcrest to develop written documents into user friendly and more easily understandable documents. The documents still also contain information, which needs revision and expansion. Examples are that there are still no details of the size of rooms or relevant Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 13 qualifications and experience of the registered provider in the statement of purpose; and the service user guide does not contain details of funding arrangements, payment of fees or any additional costs, which may be incurred by the resident. The admission procedure in the Statement of Purpose states, Hillcrest welcomes residents irrespective of their religion, culture, race or ethnic origin, political affiliation, gender or sexual orientation. The sole criterion for admission to Hillcrest is the perceived ability of the home to provide assessed care needs. This procedure is not clear about meeting assessed and identified needs and makes no mention of the needs of the residents who may already be living at Hillcrest. The acting manager states that there is a change to the organisation’s Responsible Individual, who is the newly appointed Managing Director and RI. The acting manager was unsure if an application had been made to the CSCI Regional Registration Team in respect of the change. The area manager confirmed that the RRT are involved. We have clarified that an Inspector from the RRT has informal information but at the date of this inspection visit no formal application for a change to the Responsible Individual had been received. There are currently 4 service users, 3 male and one female. One person has lived at the home for approximately 10 years. One new resident has been admitted to Hillcrest since the last Key Inspection, this admission took place in August 2007. The organisation has introduced comprehensive assessment tools so that new and existing residents’ needs can be measured and met. We have looked at the case files for two residents, one person who has lived at the home since February 2002 and the newest resident admitted in July 2007. The assessment information relating to the resident who has been at the home since 2002 recorded by the manager from another area is inconsistent and confusing for example the GP is recorded as Dr Joy but there is a letter on file from the consultant psychiatrist to Dr Price and when we asked for clarification we are told all four residents are now registered with another local GP. This resident’s financial arrangements are recorded as Local Authority Funding and being managed by a named individual but there is no indication of this person’s status. The care plan states, “Advocacy not needed, has family who take care of X’s affaires”. Other information about personal care needs states, X will go to toilet unaided”, whilst under a separate confusing assessment heading, later states, “needs assistance with toilet and needs a continence management plan”. After much discussion and examination of documentation we have discovered that the resident has the condition, mega colon, which requires specific management, medical support, a special high fibre diet and medication. None of this information is clear in the assessment of needs or Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 14 properly translated into a coherent care plan. This resident’s assessed Lifestyle Choices & Preferences - responses recorded as 7:00am - 8:00am getting up, 9:00pm - 10:00pm going to bed No-one can explain how this information has been ascertained, as the resident has poor communication skills and there is a letter on file relating to covert medication, which states, “A decision was made by professionals and X’s family, that because she lacks capacity to consent….” The newest resident admitted to the home has basic assessment documentation completed by the deputy manager at the home but there is no evidence of the care management assessment or care plan from the funding authority. We are told that the placement was agreed by the Area Manager at short notice and that when the resident arrived on a Saturday morning with his relative staff thought it was an overnight introductory visit. Instead the relative had brought the resident complete with belongings to be admitted. We have not been able to establish whether the poor admission process is due to poor planning or poor communication. The documentation on file shows that there was an initial visit two days prior to the date of admission but there are no actual details of what took place or what was agreed. There is no letter on file confirming the home can meet this person’s assessed needs (or what the identified needs are). The staff appear to have only very limited information about the resident’s previous care arrangements and there is nothing recorded on file. A regulation 37 notification was received at the CSCI on 11 July 2007 stating that they have admitted a resident to the home in an emergency at the request of SSD and agreement by the area manager. His relatives arrived with him on Saturday without the staff being given any prior notice, they thought he was coming for a brief introductory visit EDT phoned and apologised saying that they are aware they have no admission details, assessment of need or care plan in place but this will be sent to them on Monday. The home still do not have this information on file, although the acting manager states that she has requested assessment information for all four residents. During our discussions with a visiting healthcare professional from the Intensive Support Team, working with the home to understand and manage this resident we have been given some additional information. We are told that the previous placement were unable to cope with this person’s deteriorating health and challenging behaviour, that a relative took over and was unable to provide care and accommodation and that a manager representing Hillcrest agreed to the admission on the basis that the resident’s needs could be met at this home. We are told that the resident’s allocated social worker was not available at the time of the move and that some healthcare professionals have concerns about the way the admission was managed. We also have concerns for the resident who appears to have been admitted in an unplanned way and for the three residents, all of whom have Autistic Disorders with the need for stability and known routines and have experienced someone new suddenly coming to live in their home. Additionally the acting manager tells us that she does not consider that the staffing is adequate to meet the current residents’ needs. She tells us that she has requested a review of the funding at the Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 15 resident’s reviews with the funding authority, though there are no minutes of the review meeting available at present. There is evidence from three regulation 37 notifications in the days following the admission of the new resident of an escalation in physically challenging behaviour from one of the existing residents. We have seen evidence that residents have been issued with new contracts but these contain terms and conditions, which do not appear in the Statement of Purpose or Service User Guide and there are some clauses, which may be considered unfair by the Office of Fair Trading. The contract for the newest resident does not appear to have been signed by his representative or a representative of the organisation. There is an entry, which states, “I agree to comply with the Terms and Conditions and will ensure that the above named service user will comply with them and will indemnify you against any breach thereof. I agree to comply with the Terms and Conditions as outlined in this contract and I am satisfied that “X” the Service User has read or had explained the contract of this Agreement.” Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 16 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is poor Whilst there is some evidence that care plans have improved they are still not sufficiently developed to ensure that residents and staff have the information needed to know residents assessed, and changing needs and personal goals. The home is improving systems to enable residents to participate in the planning of their care and identify their wishes and aspirations. Support for residents in taking risks is compromised by inconsistent completion of risk assessments meaning that in some instances they are not fully protected in leading an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We have looked at two of the residents’ care in detail; the care files contain large amounts of information, which is not all necessarily relevant, useful or accurate. The acting manager has told us that the existing information has not yet been sifted to decide upon whether it is relevant and needs to be transferred to the new proformas or archived. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 17 The care files are generic and have not been adapted to make them person centred. The files have an index but there are as many as 36 areas, some of which are not relevant. Examples are voting and using public transport. The sample of the two residents’ case files contain written evidence that they do not have capacity to make decisions or give consent and therefore have no capacity to use their right to vote or use public transport unsupported. The care plans have significant gaps where assessed needs are not included or do contain a clear plan or guidance for staff to provide support. Examples are that both residents have poor communication and though there is an indication that one person should have flash cards, these are not in evidence, and currently neither person has a communication passport, though there is very recent involvement from the Intensive Support Team to support residents at the home. We note from the files sampled that one person is diagnosed with Autistic Spectrum Disorder and has a medical condition; Mega Colon there is little information or guidance as to how these conditions are being managed. At the previous inspection in May 2007 visit we had reported that the resident has an autistic spectrum disorder and that there was no care plan with regard to how this impacted upon her daily life and what support was needed. At that time staff agreed that they were not all fully aware of how to support or communicate with someone who has autism and they agreed that they needed more training. We are concerned that the training has not been provided and this resident has needs, which remain unmet. The newest resident has Downs Syndrome and associated Dementia and physical deterioration, which is not currently included as part the care plan, though this person now has significant support from a member of the Intensive Support Team, who has visited the home during our inspection visit. She tells us that she feels the home is now being more honest and open about this person’s needs and she is now in a better position to advise and support them. She is also acting as a conduit for access to other multi-disciplinary services the resident needs, which is positive. The home has started to devise separate personal plans, which are in a separate, purple file, these show some signs of improvement, with some pictures such as, “ Things I like”, and “Things I dont like, crowds, baths, showers, doctor, sleeping with light off” dated 4/11/2006, however they have not been completed. For example my life story section is not complete. The staff have started a personal plan for newest resident admitted in July 2007 but it does not have a recent photograph, though it is positive in the purple file, ‘map of people in my life’ has been completed and there are photos of the person and friends. The Life story section is not complete and though there are some examples of activities this person enjoys such as music and dancing, there is no activities plan and no indication of activities relating to dementia or maintaining this resident’s existing life skills. There is an activities Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 18 sheet for January 2008, mainly showing attendance at the Local Authority social education centre but there are no entries for evenings or weekends. We have spoken to staff about the principles of person centred planning, however staff have not received planned training to enable them to be able to successfully support residents to live the lives they wish. We note that none of the care plans sampled contain specific timescales for action or evidence the involvement of the residents. At the previous inspection there were records to show that night staff were checking residents’ during the nighttime at different frequencies. It was not clear as to why checks were being carried out. We have noted records at this visit indicating two hourly checks throughout the night. We have discussed this issue with the acting manager who acknowledges that the home does not have anything in place to show how these decisions have been reached or where they have been agreed for residents, who are assessed as not having capacity to make decisions or give consent themselves. We have stressed that the practice has implications relating to the Mental Capacity Act 2005 and impacts on residents’ sleeping patterns, dignity and privacy. The information we have received from the home states that all residents have been reviewed by a multi-disciplinary team including their social workers but unfortunately the minutes from these meetings are still not available. We are not able to judge whether any changes to care packages agreed at these meetings have been put in place. The acting manager tells that she has raised the issue of funding and that the home does not currently have adequate staffing levels to meet resident’s individual needs in review meetings. We strongly recommend that the acting manager formally write to the Local Authority, with her views and requests copies of the minutes of reviews to hold on each resident’s case file at the home. During the inspection we found that residents with more diverse communication needs find it harder to have their opinions listened to. We have not found evidence of how residents are supported to participate in the running of the home. The organisation is in the process of making significant changes to the interior of the home, such as reducing the number of communal toilets, without any indication of consultation with residents or advocates. This is discussed in more detail in the Environment section of this report. At the previous inspection we have highlighted the need for detailed care plans with regard to how residents are supported to manage their finances, however from the sample of files we have examined, these are not yet in place. We have looked at risk assessments in a sample of residents’ folders. These are generic and not based on resident’s individual and specific needs or abilities. We strongly recommended that a system be introduced to link care plans and risk assessments to ensure effective monitoring takes place and to promote a holistic approach to care management. As identified at the previous Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 19 inspection visit, risk assessments do not adequately assess all areas of risk to which residents may be susceptible. Examples from the sample of care files show that two residents’ Psychological risk assessments, “does not see any danger in his / her environment but are identified as low risk and have no clear measures documented to minimise risks in their environment. Both files have moving & handling risk assessments but no dates or signatures and do not indicate what assistance is required for use of bathing or showering. A resident assessed as, “can show physical aggression as result of his obsessive behaviour” does not have adequate risk management strategies in place. This person is also assessed as attempting to ‘run away’ but the documentation shows, “Risk Assessment - community - low risk.” This does not provide satisfactory safeguards. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 20 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 poor Efforts to increase opportunities for some residents to lead meaningful lives are compromised by staffing levels, which do not currently facilitate residents’ individual chosen preferences with regard to outings and activities. Although pictorial menu plans had been introduced to enable residents with making their choices known, these are not currently in use. There is inconsistent use of nutritional screening, weight monitoring, and menu planning, meaning that actions are not being identified in order to promote residents’ preferences and healthy eating. Staff strive to support residents to maintain important links with their families, wherever possible. This judgement has been made using available evidence including a visit to this service. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 21 EVIDENCE: We have noted information on the assessment documentation on the two residents case files sampled about their’ preferences for mealtimes, the preferred eating times are recorded as, “9:00, 12; 5pm; 8:30pm”, for each person. There is no explanation of how residents have reached these decisions, especially as it is identified that each person lacks capacity and there are no indication of who has been involved in making the choices. Information recorded on one person’s file states, not able to maintain, promote own rights, identified advocate – brother”. Other information on this person’s files indicates “only family, brother, limited contact”. The acting manager and staff on duty admit that they do not have awareness of the Mental Capacity Act or its implications for the residents who lack capacity. Further work should be undertaken to ensure routines are flexible to meet residents needs and choices and not solely for the smooth running of the home. We have discussed with the acting manager that the staffing levels and the layout of the building affects not only freedom of movement but opportunities for residents to participate in developing life skills. At the previous inspection visit we recommended that an assessment of the premises be undertaken by a qualified person such as an Occupational Therapist to ensure every effort is made by the home to ensure residents have freedom of movement and can undertake life skills of their choice. There is no evidence that this recommendation has been acted upon. However we have met a member of the Intensive Support Team who has visited the home during the Inspection and she tells us that she will be facilitating an assessment of the premises in relation to the newest resident who has deteriorating physical health in addition to learning disabilities and dementia. This is a positive development, where the home could access advice on behalf of other residents. During the inspection two residents have been taken to the Local Authority social education centres and one person has been taken to visit their parent, in a local nursing home. The fourth resident has spent most of the day at the home and has been involved in showing us some parts of the home. The residents still tend to go out as a group, as the staffing levels are not adequate to support residents on individual outings or activities outside the home. Two residents returned home at 12:05pm, and have been taken into lounge and asked to watch TV by member of staff. The residents watched Elvis DVD’s during the evening of the visit, when there have been only two staff on duty. One of whom is an expectant mother; this issue is discussed further at later sections of this report. We have discussed with the acting manager that progress must now be made to ensure residents can undertake activities on an individual basis in order that Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 22 their individual needs and preferences are recognised and met, promoting a person centred approach to care. We note that some food preferences are recorded in the assessment and care planning information. The two residents case files sampled show that they have special dietary needs but there is insufficient information to evidence that they are adequately met. One person requires a high fibre diet to help control a ‘mega colon’ condition and there is an instruction that their fluid intake is recorded. The acting manager has explained that she is revising the menu and the pictorial menu is not currently being used. The staff are not recording the resident’s fluid intake. It has not been possible to assess whether the resident’s nutritional needs are being met. The newest resident is assessed as needing ‘soft diet’ options, as this person has no teeth or dentures and verbal information from the IST staff indicate this person also has dysphasia. There is insufficient information recorded to assess whether this person is being provided with a nutritious diet. We have observed the residents at home being told “its sandwiches today, cheese or ham.” One resident has been asked “bread or crisp bread.” We also observed the evening meals being prepared during our visit, the written menu states chicken casserole but the staff have heated a shepherd’s pie ready meal. The staff have told us that there is no chicken casserole sauce mix and have cooked what they could find. The residents have not been consulted. One resident asked for a tin of chicken soup as an alternative but this was not available and the only soup the staff could find was mushroom, which the resident accepted. We have noted that though a shopping list had been prepared in the manager’s office, the stocks of food in the home are very limited. There are no fresh fruit, vegetables or salad items, apart from an apple and onions. There are no adequate records to demonstrate that staff are following a planned daily nutritious menu for each resident. Furthermore we observed a resident ask for a banana but there are none available and staff offered an apple, the only fruit available. The acting manager states that the residents do not like shopping for food and the only female resident refuses to get off the mini-bus. However we recommended that residents be given the opportunity to be involved in food shopping, on an individual basis, as this is currently not taking place. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 23 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 poor Though staff show an improved understanding of the concept of valuing people and there is insufficient evidence to demonstrate that personal support is always provided in accordance with residents’ expressed needs and wishes. There are some significant areas where needs are not well managed at present, which have the potential to place residents at risk. Though systems for dealing with potential risks to health are showing some signs of improvement there are weaknesses, and are not sufficient for promoting and maintaining service users’ wellbeing. The current procedures for administering medication pose serious risks to residents and need immediate improvements so that all residents are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Though efforts are being made to promote residents rights to privacy, dignity and choice with regards to personal care and support, this is hampered by the lack of choice of bathing and toilet facilities and lack of male staff. This means that residents are not always able to choose which gender to support them. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 24 Care records have information relating to residents preferences about when they wish to get up or go to bed. However as highlighted throughout this report there is no evidence as to how these decisions have been made with people who lack capacity. There are ‘consent’ forms regarding same or cross gender care, door locks, keys, lockable space etc. As highlighted earlier in this report action must be taken by the home with regards to consent/capability to ensure the homes practices and documentation comply with the Mental Capacity Act 2005. During our tour of the home we found two communal toilets have been removed, and the only bath in the home is not functional, which compromises residents’ rights to choice, privacy and dignity. At the previous inspection and as highlighted earlier in this report, we recommended that the practice of undertaking regular checks during the night for residents be reviewed and only undertaken if agreed within a multidisciplinary forum to ensure residents rights to privacy are not encroached upon. We have found that records confirm that these checks still take place, with no evidence of the resident’s need or best interest. There are letters on each resident’s file to show that they have received a review of their healthcare needs by their consultant psychiatrist in January 2008. However the letter’s are written or copied to named Doctors’ who do not appear to be their current GP, as the organisation has taken the decision that all residents be registered with the same GP, which is a matter of concern, relating to rights and choice. This concern is reflected by other healthcare professionals in returned surveys, “One concern is that Hillcrest (and the organisation Select Healthcare) have registered all the service users with the same GP for all their homes. This does not seem to match with the values of PCP another healthcare professional has commented about what the home could do better, There have been occasions where support staff could have improved this by NOT discussing and their needs, but finding a private area to talk. Also, I have at times heard people asked to go to the toilet or for other personal care - this could have been done in a more discreet way.” The acting manager is attempting to improve systems for ensuring the of health care needs of residents, though further work is still needed to ensure effective monitoring can take place and the health needs of residents are met. We have seen files containing health appointment sheets, which detail the date and what healthcare professional they saw but none contained sufficient detail of why the visit took place, actions taken or outcome. A comment from the healthcare professional survey states, They appear to be making contact with relevant agencies re health care, again the main work at the moment relates to setting baselines for people that were not evident or there with the previous organisation. We have been able to discuss involvement with healthcare agencies with a member of the Intensive Support Team, visiting the home to support the newest resident. She confirms that progress is being made, though the home has a long way still to go. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 25 We have also found weight-recording sheets in place on residents’ files, but there are two different formats, with inconsistent recordings and no explanatory comments. The resident who has the ‘mega colon’ condition has records for bowel movements with guidance for staff but information has not been completed in accordance with instructions. Nutritional screening tools have been completed, meeting a previous recommendation, and a body mass index calculator is now in place at the home, but as yet this has not been used. We have discussed the partially completed Priority for Health Screening’ in place at the previous inspection but not in evidence at this inspection; and she has explained that this is going to be started afresh with support and input from other agencies involved in each person’s care. We have noted written information on each person’s file relating to breast awareness and testicular cancer awareness but there is no written guidance as to who or how this is to be achieved and whilst it is positive the home is considering these issues there are significant implications for supporting people who do not have capacity to give consent. We strongly advise the acting manager to seek support from the multi-disciplinary team to put in place written protocols for observation for health screening. The home has a copy of Select Healthcare medication policy and procedures and uses the BOOTS MDS system. A comment from the healthcare surveys states, my only insight in this area has been the use of PRN medication, staff previously did not give it early enough. Staff now seem to recognise that given correctly it can be a useful tool to supporting someone to relax, also protocols for PRN have been written, which is very positive. There are signatures of all staff working at the home on the staff specimen signature sheet, including someone no longer at the home. We recommend that only the specimen signatures are held of staff trained and assessed as competent to administer medication. The home is not currently following the organisation’s medication procedure in that prescriptions are generated from the GP surgery not the home. The prescriptions are sent directly from the GP surgery to the pharmacy and the dispensed medication is delivered to the home. The home does not have copies of original prescriptions and there are discontinued items on the MAR sheets, which the home needs to request be removed to avoid confusion. Some MAR sheets have handwritten entries or corrections and these are not currently signed and witnessed by two members of staff who are competent to do so. One medication record does not have a photograph of the resident and though the MAR sheets are generally well completed there is one gap, with no signature or code entered and there are no carried forward balances of any medication stocks each month, which makes internal audits of medication stocks difficult to undertake accurately. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 26 We have observed that senior care staff remove medication from the medication cupboard on the first floor and use a tray to take it to administer to the residents, who are usually on the ground floor. We have issued an immediate requirement to the registered person who is required to ensure that the practice of secondary dispensing and unsafe medication administration ceases with immediate effect and ensure that an appropriate system of medication administration for each resident is implemented to minimise any potential risk of error or harm. The acting manager has explained that new storage has been obtained from BOOTS but it is too large to fit in the existing room and alternatives are being considered. We have discussed the issues, which may occur with the proposed new arrangements and strongly recommend that the acting manager seek the view of the CSCI pharmacist before implementing new storage arrangements. Contact details have been made available to the home. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 27 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. There is a complaints procedure and though not all residents are sufficiently supported to express any concerns and to understand how to access this process. Improved recording systems have not yet been put in place. Although there are written policies and procedures in place to safeguard adults from abuse there are practices and failures to minimise risks, especially in the environment, which have the potential to place residents at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed in full view in the home for all visitors to see. The home’s AQAA states that there is an open door policy and anyone can approach any staff member with whatever concerns they may have. Staff are aware of the company policy on confidentiality and are assured that any concerns are investigated thoroughly. Staff concerns can be raised in regular supervisions’. Evidence obtained during the inspection indicates that some aspects of this information are accurate while others are not. For example there is a comprehensive complaints procedure that has been reproduced in a pictorial format for residents and relationships between residents and staff have been observed to be relaxed, with residents and staff communicating freely to one another, promoting at atmosphere where residents are encouraged to raise concerns. The complaints procedure has not been seen to be on display within the home and records of staff supervisions do not demonstrate they are occurring on a regular basis. Residents living at the home with communication needs are more reliant on staff to raise concerns on Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 28 their behalf and ensuring staff receive regular formal supervision will promote a formal structure for this to occur. The training plan for the home states that one member of staff has undertaken protection of vulnerable adult training and that the other 9 staff employed at the home are booked on this February and April 2008. We looked at residents’ finances and carried out an audit of money, which tallied with the records maintained. We noted that on both residents personal allowance sheets finances have been spent on meals away from the home. On one of these occasions the receipt details two meals being purchased. Recordings in the daily records confirm these meals were for lunch and dinner. We discussed this with the Acting Manager, as normally 3 main meals (breakfast, lunch and dinner) should be provided by the home as part of the contract fee paid by placing authorities for residents staying at the home. No written policy for the funding of meals or payment of staff meals/use of petty cash could be found and the Acting Manager was not aware of these existing. Clarification in this area must be sought to ensure residents are not placed at risk from financial abuse. A recommendation was made at a previous inspection for the home to liaise with the Local Authority commissioners to seek confirmation and ensure the contracts and service user guide are altered accordingly to confirm whether toiletries are or are not covered as part of the fee. The acting manager was not aware of this taking place and therefore this remains outstanding. There are policies and procedures regarding vulnerable adult abuse. There was also a copy of the Local Authority multi-agency procedures ‘safeguard and protect’ plus a copy of the ‘no secrets’ guidance available at the home as is good practice, though there are no staff signatures to demonstrate that they have read and are aware of the guidance. A Requirement was made at the previous inspection that arrangements must be made to ensure that all staff have a clear understanding of adult protection and whistle blowing procedures, to ensure that residents are not at risk of harm or abuse. The Acting Manager informed us at this inspection that all but one member of staff have now completed vulnerable adults training. However the training matrix and certificates on staff files do not confirm this. At the previous inspection a requirement was made to make arrangements to ensure that physical and verbal aggression by a resident is understood and dealt with appropriately by staff, to ensure that residents are not at risk of harm. We have looked at the records of challenging behaviour, some of which are incorrectly filed and do not contain sufficient detail of the antecedent to the behaviours or consequences. In discussions with the acting manager she acknowledges that staff need training to raise awareness and skills to record and respond appropriately to incidents and behaviours, which challenge the service. We are told by a member of the Intensive Support Team that the team Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 29 is working more closely with the home to provide staff training, improve understanding and provide better strategies and safeguards for residents, which is very positive. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 30 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, 27, 28, 29, 30 Quality in this outcome area is poor The major refurbishment programme has stalled and has failed to provide residents with a more comfortable and homely environment. The premises present significant risks to residents’ safety and some of the changes potentially compromise residents’ rights to privacy, dignity, choice and independence. The home is generally clean and tidy though some aspects of infection control still need some improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We have undertaken a tour of the premises including viewing of residents’ rooms who consented to this. At the previous inspection major refurbishment and decoration of the building was in process. At this inspection we have found that this has not continued, with areas of the building requiring attention. When asked why work is not progressing, we are informed that the Contractors have been ‘pulled out’ to carry out works at another home owned by the same company as their work is of a higher priority. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 31 One resident agreed to show us her bedroom located on top floor. This has an en-suite shower in place. We have noted that the shower basin is soiled under the bathmat. In addition to the shower unit there is a sink with overhead mirror and light fitment, however there is no light bulb in place. Furniture in the room consists of a built in wardrobe with ample storage space, bedside chair and cabinet. The door hinge to the cabinet is broken causing the door to fall open. A window restrictor is fitted to the window for safety but this is broken allowing the window to open fully. We have also noted that there is no lockable facility in the resident’s bedroom however a good quality door lock that can be controlled by the resident is fitted to the bedroom door (with a safety over-ride device in place). The bedroom is clean and decorated to a good standard with lots of personal items including ornaments, dolls, and music system. On the first floor there is a room that was previously a toilet. We are informed the toilet was removed due to the floor sinking. No one could tell us what this room is going to be used for. This floor of the building has 3 bedrooms (one of which is currently vacant), and the staff sleep-in room, which includes a shower-room with a toilet. Without the now defunct toilet if a resident wishes to access a toilet when someone is using the shower they have to go to the middle or lower ground floor. Whilst this alone may not seem untoward for residents, there is the additional issue of the bath located on the lower ground floor, which is out of use resulting in all residents having to use the shower room as this is the only bathing facility apart from the en-suite in the resident’s bedroom. We are also told the resident does not like to use this facility. The shower room on the top floor requires refurbishment to ensure it is homely and to promote good infection control measures. The ceiling has paint peeling, areas of the walls are damaged with tiles missing, paintwork is chipped and stains can be seen to the walls and floor. We are informed that refurbishment of this room should start next month, February 2008. A ready supply of paper towels, liquid soap, gloves and aprons are available in this room, as is good practice. In addition to changes to the top floor of the building we found that a toilet has been removed from use on the middle floor. This room is in a state of disrepair and not fit for use. We are informed that the room is going to be changed to a room for storing the medication cabinet. We could find no evidence that residents have been consulted with regards to changing of rooms and witnessed one resident open the door to the room that was previously the toilet and ask staff “where has the toilet gone”. Staff informed him it is no longer there and told him to use another located adjacent to the ‘quiet room’. The result of decommissioning this toilet is that residents still have access to a toilet on this floor but that the remaining toilet opens onto the ‘quiet room’. This potentially impacts on residents’ privacy and dignity. We have viewed the remaining toilet and found the flooring to be ripped and stained at the Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 32 entrance posing a potential trip hazard. We have issued an Immediate Requirement Form regarding this, instructing the home to reduce the risk of injury to residents. An extractor fan is sited in this toilet that is very noisy. No one could confirm if it has been serviced. The walls and flooring to this facility are stained and there is a hole to the rear of the toilet basin. As with all other toilets paper towels and liquid soap are in place as is good practice. No hand washing signage is displayed in any areas of the home. This should be provided in formats suitable not only for staff but for residents to ensure good infection control measures are practiced. The bath in the bathroom on the lower ground floor cannot be used due to leaking pipe work. The acting manager is unable to say how long the bath has been out of commission, but states it had been out of use for as long as she has worked at the home, at least past three months. We have found the flooring to be a trip hazard due to being raised between the door and hallway. We have issued an Immediate Requirement Form instructing that the risk of injury be reduced. As already highlighted, apart from one resident with a bedroom with an en-suite shower, there is currently only one other bathing facility that is available to residents, a shower on the middle floor. Currently there are 4 people living at the home. The home is registered for up to 7 people. Until the bathing arrangements are improved we recommend that no more residents should move into the home as the increase in numbers and lack of facilities would impact on the privacy and dignity of people living at this home. The acting manager has discussed with us the possibilities of changing rooms within the home and altering facilities. She is unable to say if discussions regarding these have been held with CSCI. Formal discussions should take place and formal agreement sought before any changes to facilities and rooms take place to ensure any changes made are in the best interests of residents. Any changes should also be made only after consultation and in agreement with residents. Another resident gave their consent for us to view their room located on top floor. This bedroom is also clean and tidy, decorated to a good standard and includes a lockable bedside cabinet. The window restrictor in this room is also broken allowing the window to be fully opened. The acting manager has informed us that restrictors were going to be replaced and produced a sample product. She cannot tell us when this work is going to be completed and confirmed that a written risk assessment had not been completed regarding the potential risk posed to residents. Due to concerns regarding window restrictors an Immediate Requirement Form has been issued instructing that action be taken to reduce risk to residents. We did not view the resident’s bedroom located on the middle floor as it was locked and we did not have their permission to enter. We viewed the resident’s bedroom located on the lower ground floor with their permission. This is clean and tidy, and decorated to a good standard with lots of personal items reflecting the individual’s tastes. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 33 An office is also located on the top floor of the home. On arrival at the home we observed the door wedged open. We raised concerns regarding this with the acting manager as this is a fire door and the practice of wedging fire doors open could increase the risk of injury to residents in the event of a fire. The acting manager informs us “its good to hear what’s going on downstairs”. We have advised that if the door needs to be kept open then an appropriate opening device fitted to the fire alarm system must be installed. The office contains equipment including a filing cabinet used for storing staff recruitment documentation (the lock was seen to be broken), a small safe, photocopier and fax machine. There is currently no computer system available with the acting manager confirming that she takes work home to be typed up due to not having a computer within the home. The dining room is located on the middle floor of the building. We have noted that there is a large radiator that has no covering and was hot to touch. During the evening of the inspection visit we have noted that an older resident with physical disabilities and dementia in addition to learning disabilities leaning on and touching this radiator. As with the unguarded radiators in residents’ bedrooms the acting manager confirms no risk assessment having been completed. The walls have been painted in this room however it is noted that gloss paintwork around the skirting boards is chipped in places and chairs do not match the dining table, giving a tired and worn feel to the room. We are told that the furniture is ‘second hand’ and the residents and staff would appreciate some new furniture more appropriate to the needs of the people living at the home. When entering the lounge we noticed that the floor appears uneven near the centre of the room. No one could explain what might be causing this or if any investigation had taken place. We found the only items of furniture in the lounge to be a 3-piece suite (of which one arm is damaged) and a television cabinet, which was secured to the wall (the drawer to this was also damaged). We are informed the lack of furniture is due to the behaviours of some residents who would damage items if available. As all of the bedrooms that we viewed had items of decoration we question how the decision to furnish the lounge has been made and recommend that this be investigated to ensure management of behaviours does not impact unnecessarily on the decoration of this room. The home has a large, bright kitchen that is currently in the process of being decorated. The acting manager informs us that new flooring will be fitted and that a new fridge is on order because the current one is not maintaining safe temperatures. We are informed the fridge is not in use however when we opened it we found milk, bread and pop stored in it. We have instructed that these be removed to promote good food hygiene standards. Dudley MBC Department of the Urban Environment – Food and Health & Safety carried out an inspection of the kitchen September 2007 and issued 4 legal requirements. We found evidence of action taken to address some of these, with others Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 34 requiring further work. When examining food stocks we found both brown and white bread available, a choice of cereals, UHT and semi skimmed milk and stocks of tinned food items. There is no evidence of fresh fruit apart from one apple available and no fresh vegetables (apart from potatoes) or salad items. Access to the lower ground floor of the home is via steps from the quiet lounge on the middle floor. We have discussed the issue of access with the acting manager who informs us some residents have input from the Occupational Therapy team for specific areas of need but is unsure if this includes assessing the environment. We recommend that an assessment of the premises be undertaken by a suitably qualified person to ensure every effort is made to provide aids and adaptations that encourage free movement for residents. A recommendation was made at a previous inspection to seek advice from a relevant agency to ensure the building and garden areas comply where possible with the Disability Discrimination Act 2005. We could find no evidence of action being taken in this area and the acting manager was not aware of any either. We found a strong odour in the lower ground floor toilet. The acting manager states this is from the sani-flow system and nothing can be done. Paper towels and liquid soap are in place promoting good hand washing but again there is no appropriate signage. We are concerned to see coat hooks mounted to the wall in this room with clothing that appears to have been used for decorating. The flooring is stained and there is no lock to the toilet door. We found a cupboard located in this room used for storing cleaning items. Consideration should be given to moving this to promote good infection control measures. There is room on the lower ground floor that was previously a laundry and is now being used to store paperwork. This is not secure and action should be taken to ensure records are stored in line with Data Protection Act 1998, promoting peoples rights to confidentiality. This room is also being used to store mops and buckets. The mops are not hung up or stored inverted and the acting manager informs us there is currently no appropriate storage facility nor is there a sanitizing programme currently in place. She did however state that staff regularly clean the mop heads and spare mop heads could be seen to be in place. There is a small laundry room located on the lower ground floor of the home. This has a small commercial washing machine with disinfection programmes and a domestic dryer. Some areas of the walls are damaged and flooring stained. There are no infection control policies or guidance on display to inform and advice staff. The acting manager informs us these are kept in the office. We strongly recommended that these be kept in the laundry for easy access. We also note that the infection control guidance currently in place was issued in 1996. We recommend that the home obtain the most up to date Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 35 guidance issued by the Department of Health in 2006, to ensure staff practices reflect current good practice guidance. During the tour of the building we have noted that this is no signage displayed in compliance with the Smoke Free Regulations. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 36 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): 31, 32, 33, 34, 35, 36 Quality in this outcome area is poor Some practices observed and discussions with staff demonstrate some improvements, however there is evidence that there are inadequate staffing ratios, which do not meet the needs of service users and not all staff have the appropriate skills and knowledge to support people living at the home. There is a lack of documentation in relation to newly recruited staff and agency staff has the potential to place people at risk. The organisation is not committing sufficient resources to staff training and development and comprehensive and there is insufficient evidence of structured inductions for new staff before they work with residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection we observed relationships between residents and staff to be positive, with residents appearing comfortable to talk to staff. Staff that have been spoken to are able to describe residents individual needs. For example one member of staff explained, “you need to build up trust with X, its very important to X, particularly when getting ready with personal care. We have had a bit of trouble over the last couple of years with showers, just Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 37 doesn’t want to get in. Used to love a bath but started having same trouble not wanting, we have been working with the intensive support team trying different things, has been improving, you have to be patient, allow time”. It is a positive that all staff apart from one person either hold a National Vocational Qualification (NVQ) level 2 or 3 or are in the process of obtaining this. In addition to this we are informed that the deputy manager and both senior carers have been enrolled on the NVQ level 4 and are currently in the process of completing this. All staff that have been spoken to praised the training opportunities provided to them. As one person explained, “training provided much better since new owners, give you time to do it”. Discussions with staff and examination of documentation indicate that staffing levels do not always meet the needs of residents. There are currently 4 people living at the home, two who have been assessed as high dependency, 1 medium and 1 low. We are informed that for two residents they require two staff each to access activities out in the community. Rotas evidence that on the majority of shifts there are only 2 care staff are on duty. In addition to this the manager is on duty from 7am to 2pm Monday to Friday. A driver/maintenance person is also on duty from 8am to 4pm Monday to Friday and a domestic 11am to 1pm Monday to Friday. The home does not employ separate kitchen or domestic staff with these duties being undertaken by the care staff on duty. Staffing is of a particular concern during the afternoon and early evening as this is when only 2 members of staff are available in the building. They have to provide any support needed to residents, prepare and cook meals, carry out any domestic duties and undertake administrative duties such as answering the phone. Evidence from records show that very few off site activities take place during the afternoon and early evening. We have looked at the staff rotas for 03/12/07 to 21/01/08. These evidence that when the driver and domestic are on leave their shifts have not always been covered (9 shifts in this time period for the driver and 19 for domestic). In addition to this for the same time period 2 shifts were not covered when the acting manager was on leave. The reduced staffing levels have the potential to place residents at risk and of not having their needs met. We sampled 3 permanent staffs recruitment records and the records of 3 agency workers who have recently undertaken shifts at the home to see if the homes practices safeguard residents. All of the permanent staffs files contained 2 references, application form, enhanced Criminal Bureau Disclosures, at least 2 forms of identification and contracts of employment. All however had areas that could be improved to offer further protection to residents. For example the references for one member of staff were not on company headed note paper and there was no evidence of validation of authenticity, contracts of employment for two staff had not been signed by either the employee or employer, a member of staff who commenced employment on a POVA first did not have a written risk assessment completed (as recommended by the Department of Health), the references for another Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 38 member of staff included one from their most recent employer but this was given by a work colleague and not a manager and one recruitment file did not contain a photograph of the individual. All files contained evidence of interview questions and responses however none contained evidence that residents have been involved in the recruitment and selection of staff. Disciplinary records are maintained on staff files, as is good practice. It is a matter of concern that actions as a result of a disciplinary investigation have not been carried out in full. For example it states that the member of staff must have weekly supervision for 1 month, changing to monthly. We found supervision records in place for 16/07/07, 21/08/07 and 28/08/07 with no others available. A supervision matrix was viewed and states supervisions for this person took place 24/10/07, 15/11/07 and 03/12/07 but no records are on this persons file to confirm they took place. Of the 3 agency workers to have recently worked at the home records are available for 2. Both need further action in order to demonstrate individuals are suitably qualified. For example a letter was found on one of the workers file from the agency stating the hold first aid, food hygiene, health and safety, moving and handling and fire but not when they achieved these. The second file contained a form for documenting training undertaken but this had not been completed. This same persons file contained a staff profile that states they have an enhanced POVA disclosure but does not say when issued or give a serial number. We have been unable to ascertain accurately numbers of staff having undertaken training in various areas specific to their roles, as documentation supplied during the inspection appears to contradict each other. For example we have been shown a training plan for the home for 2007/08 that details 10 staff. This states 4 having undertaken fire 2007, none infection control, 4 challenging behaviour, none communication, none COSHH, 7 infection control, 4 food hygiene, 2 health and safety, none manual handling, 1 first aid, 6 NVQ2 or 3, 3 in process of completing NVQ 4, 7 having started common induction 2007, 1 LDAF, 4 autism awareness, 1 principles of care, 1 POVA, 6 medication and 2 care planning. It also details future training dates for some staff in health and safety, first aid, food hygiene, infection control, POVA, mental health, LD awareness and holistic assessment. When examining certificates on staff files we found one containing a fire certificate that was not included on the training plan and the same person had an individual training record that states they hold health and safety, moving and handling and first aid but no certificates were available to validate this. Another member of staff file contained certificates for epilepsy and abuse (not on training plan) and moving and handling that had expired. A third member of staff’s file contained a certificate for fire safety, abuse and epilepsy (not included on training plan). Information contained on the training plan was further questioned when one member of staff explained that they had not undertaken any training and did not hold any qualifications, informing us “dates had been booked but all cancelled”. The acting manager confirmed that as yet no arrangements have Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 39 been made to receive equal opportunities, person centred planning or Learning Disability Award Framework-accredited (LDAF) training. We were however informed that all staff have started the Common Induction Standards which when completed would allow them to progress towards LDAF. Staff receive some formal supervision however this could be improved. None of the staff files sampled contained evidence that they receive at least 6 formal supervision sessions per year, as is good practice. As with training information supervision records appear to contradict one another. For example records of meeting on one individuals file detail supervisions occurring July and August 2007 but a supervision matrix details supervisions taking place October, November and December 2007 (no records could be produced for these dates). This is the case on all files we sampled. We also noted that one member of staff has not received any formal supervision since August 2007. In addition to this none of the staff we spoke had undertaken an annual appraisal. Support is however been given to staff in the form of staff meetings. Records evidence these occurring on a regular basis. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 40 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, 41, 42 Quality in this outcome area is poor The new management arrangements at the home are at an early stage and indicate some signs of improvement in a small number of areas, such as better communication within the home, with relatives and with external healthcare providers. The introduction of an effective quality assurance system would ensure that residents’ views are taken into account and help to shape the service provided. There are still poor outcomes detailed throughout this report and continue to compromise residents’ safety and wellbeing This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager has been in post for 3 months. We have not been able to look at her recruitment and training records as these are maintained at the company’s head office. She informs us that the holds a NVQ level 4, which she achieved in 2005/06. In addition to this she informs us that she holds all Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 41 mandatory training. We discussed what this consisted of and have been informed courses undertaken were the same as care staff. We recommend that as manager she should undertake courses that offer more in-depth knowledge than those provided to care in order that she has the appropriate knowledge to monitor staff practices. During the inspection the acting manager appeared willing to work with us and gave explanations on how she wants to improve services within the home, however on several occasions when asked if she had completed documentation such as risk assessments she said that she had but when asked to produce them she informed us she had not “actually” started them. As yet the acting manager has not submitted an application for registration with CSCI. There is a quality assurance system in place that is not yet fully operational. We are informed that surveys have been sent to stakeholders and families but these are not due for return until the end of January 2008 and so analysis of findings has not yet taken place. We noted that surveys are not available for staff to complete. It is recommended that these be implemented as a further aid to quality monitoring. A development plan was not available to view, with the acting manager unsure if one existed. The Area Manager undertakes regular visits to the home in line with Regulation 26 of the Care Home Regulations 2001 and copies have been forwarded to CSCI. Residents’ surveys were completed November and December 2007 however two of these have been completed by staff and give their views and not the residents. It is a positive that the use of Widget symbols is included as aids to communication for residents but further improvements could be made with the use of colour and large print. The use of independent advocates to support residents to complete these would also enhance the process further. Information supplied by the home prior to the inspection in the form of its AQAA states that residents meeting take place monthly. Records available in the home do not reflect this statement and those in place are basic in terms of content and do not demonstrate residents are supported to make decision regarding the home. For example the records of the meeting held 18/01/08 state ‘X would like new slippers, X slippers and batteries, all seen dentist 23/01/08, activities planned pear tree, in-house activities, X to visit dad’. The home has a quality assurance policy in place. This was found to be incomplete in many areas that should detail who responsible for undertaking aspects of monitoring. Audit forms are in place for areas including key worker development plans, care plan reviews, service user risk assessments and business plan evaluation and updates however all of these were found to be blank. Audits had been completed for daily quality food (completed 21/11/07, 17/12/07 and 16/01/08) and medication (completed September 2007, 24/12/07 and 15/01/08). Discussions have taken place relating to the new Regulation requiring the home to submit an annual AQAA on request by the CSCI and it is Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 42 recommended that the registered manager proactively use this as an additional tool. In addition the evidence to support statements made in the AQAA need to be more detailed and accurate, as the evidence will be tested and verified as accurate or not during inspections. There are a range of policies and procedures in place for most aspects of service provision. As already mentioned earlier in this report none are in place for the use of residents monies or funding of staff meals. Nor could the acting manager locate polices for the Mental Capacity Act. None of the policies sampled had been signed or dated by the acting manager or a representative of the company. Neither could evidence be found that staff read policies. The acting manager informed us that staff are aware of policies but do not sign anything to say they have read them. Further work must be undertaken to ensure so far as reasonably practicable the health, safety and welfare of residents and staff. For example not all staff listed on the current duty rota have undertaken a fire drill within the last 6 months (of particular concern is night staff who have not completed this). It was also noted that records of fire drills do not include at what time of day or night the drill took place. It is recommended that drills occur at various times of the day and evening in order that the home can be confident appropriate action will be taken in the event of a fire. No evidence could be found that all gas appliances have received an annual inspection, no records were available to confirm portable electrical items having being tested and a five year fixed electrical wiring certificate was not available. In addition to this there are omissions in written risk assessments. For example the acting manager confirmed written risk assessments have not been completed for Legionella, asbestos, and staff transport. An assessment is in place for items in line with the Control of Substances Hazardous to Health but this requires reviewing, as it does not reflect accurately chemicals and omissions in documentation with in the home. For example when sampling products several data sheets were not available and risk assessments were have not been completed to inform and advise staff. The home has a contract with a pest control company who have visited the home twice in January 2008. The acting manager confirmed that a risk assessment has not been completed with regards to pest control. During the visit we observed a pregnant member of staff on duty. We were pleased to find that a risk assessment had been completed regarding this member of staff and identified ways of reducing potential risks to the individual. The risk assessment states that an extra member of staff must be on shift when the named staff member is on duty and that the staff member must not undertake any personal care. We are concerned to find that a third member of staff was not on duty and the other member of staff who was on shift has received no training to date. The person who is pregnant is also the senior sleeping in, on call on some night shifts. These situations place residents and staff at serious risk. Due to our concerns we issued an Immediate Requirement Form during the visiting instructing the acting Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 43 manager to ensure risks are reduced and that further advice be sought regarding the employers responsibility in compliance with the Management of Health & Safety Regulations 1999. The home has its own vehicle. We have not been able to look at any records regarding the maintenance and up-keep of the vehicle; the acting manager informs us that all records are kept at head office. We asked what checks are undertaken on a daily/weekly basis and we are informed the driver completes a visual check and records mileage. We recommend a record be maintained within the home of daily/weekly checks to seatbelts, water, oil, tyres etc to promote good safety management. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 44 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 1 4 2 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 2 27 1 28 X 29 X 30 1 STAFFING Standard No Score 31 2 32 1 33 1 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 1 1 X LIFESTYLES Standard No Score 11 X 12 1 13 1 14 1 15 2 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 1 X 1 X 1 2 2 1 X Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 45 Are there any outstanding requirements from the last inspection? YES Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement There must be a detailed plan in place as to how the residents’ needs in respect of health and welfare are to be met thereby ensuring that their health, safety and welfare is not jeopardised. For example with regard to providing support for people who have autism, people who have mobility problems, covert administration of medication and management of night time routines. (Timescale of 01/09/07 Not Fully Met) It is the home’s responsibility to notify the CSCI when this requirement is met. 2 YA13 16(2)(m) To provide more opportunities for service users to engage in local, social and community activities, which must be based on their individual preferences and needs – thereby promoting and making proper provision for their health and welfare. (Timescale of 01/09/07 Not Fully Met) DS0000069595.V357555.R01.S.doc Timescale for action 01/04/08 01/04/08 Hillcrest (Stourbridge) Version 5.2 Page 46 3 YA20 13(2) It is the home’s responsibility to notify the CSCI when this requirement is met. The registered person is required 22/01/08 to ensure that the practice of secondary dispensing and unsafe medication administration ceases with immediate effect and ensure that an appropriate system of medication administration for each resident is implemented to minimise any potential risk of error or harm. It is the home’s responsibility to notify the CSCI when this requirement is met. The registered person is required 22/01/08 to ensure that written risk assessments are devised and implemented for each broken window restrictor on full length opening windows on the first floor within twenty-four hours and submit written proposals for the repair or replacement of window restrictors on all affected windows within an identified timescale It is the home’s responsibility to notify the CSCI when this requirement is met. 4 YA24 13(4) 5 YA24 13(4) The registered person is required to ensure that written risk assessments are devised and implemented for all exposed radiators and pipe work in bedrooms and communal areas, which are excessively hot to touch and accessible to residents, within twenty-four hours and submit written proposals to minimise the risks by provision of either low surface temperature radiators or guards, DS0000069595.V357555.R01.S.doc 22/01/08 Hillcrest (Stourbridge) Version 5.2 Page 47 within an identified timescale It is the home’s responsibility to notify the CSCI when this requirement is met. 6 YA24 13(4) The registered person is required to ensure that written risk assessments are devised and implemented, with remedial action to minimise the risks of the raised flooring in the middle floor bathroom and lower floor bathroom / toilet posing trip hazards to residents and staff, within twenty-four hours and submit written proposals for an appropriate permanent solution within an identified timescale It is the home’s responsibility to notify the CSCI when this requirement is met. 7 YA33 13(4) 1) The registered person is required to ensure that control measures identified on the written risk assessment relating to the pregnancy of the senior member of staff are adhered with immediate effect i.e. that there is a suitably trained and competent third member of staff on all shifts with this person to minimise risk of harm to residents and staff. It is the home’s responsibility to notify the CSCI when this requirement is met. 8 YA34 19(1) To cease the employment of any temporary staff without obtaining written confirmation that they have received satisfactory police clearance checks (CRB and POVA), and have undergone suitable training DS0000069595.V357555.R01.S.doc 22/01/08 22/01/08 22/01/08 Hillcrest (Stourbridge) Version 5.2 Page 48 prior to them commencing duties – Immediate and on-going within 24 hours of the inspection. (The previous timescale of 11/05/07 is Not Fully Met) Further breaches of this Regulation may result in Enforcement Action by the CSCI It is the home’s responsibility to notify the CSCI when this requirement is met. 9 YA42 13(4) 1) The registered person must ensure that appropriate self closing devices, approved by West Midland Fire Service, are installed to any door which needs to be propped open, examples are the office and resident’s bedroom 2) The registered person is required to ensure that all staff listed on the current duty rota have undertaken a fire drill within the last 6 months (in particular night staff who have not completed this training) It is the home’s responsibility to notify the CSCI when this requirement is met. 01/03/08 Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 49 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations To expand the statement of purpose to include all details required by the Care Homes Regulations 2001, Regulation 4 and Schedule 1 for example details of room sizes and qualifications and experience of the registered provider. Not Fully Met To expand the service user guide to ensure that it contains all of the details required by the Care Homes Regulations 2001, Regulation 5 such as details regarding fees and who will be responsible for paying them and information regarding additional charges. Not Fully Met To consider producing the service user guide in formats suitable for residents. Not Fully Met 2 YA2 To continue to carry out and complete assessments of existing residents’ needs and to keep these under review. Not Fully Met That there is a copy of the care management assessment and care plan on each resident’s file as evidence of their assessed needs That there is documentary evidence of how the home has planned any new admissions, including consideration of the existing residents That a copy of the correspondence to the resident and / or their representative confirming that the home can meet their assessed needs is held on their case file It is recommended that no further residents should move DS0000069595.V357555.R01.S.doc Version 5.2 Page 50 3 YA3 4 YA3 5 YA3 6 YA3 Hillcrest (Stourbridge) into the home until there are adequate bathing and toilet facilities as the increase in numbers and lack of facilities would impact on the privacy and dignity 7 YA4 That full details of all introductory visits are recorded, with outcomes and where these have not taken place, as good practice dictates, clear reasons for decisions are recorded To continue to fully complete and issue new statements of conditions of residency to all residents. Not Fully Met That the Contract / terms and conditions be reviewed and revised to demonstrate compliance with The Care Homes Regulations (1 & 5) and the guidance from the Office of Fair Trading To ensure the care plans are drawn up and reviewed in conjunction with the service user, advocate and relatives and significant professionals. Not Fully Met The Home should continue to introduce and complete a person centred approach (such as essential life style planning) and reproduce care plans in formats suitable for service users. Not Met To obtain copies of the last review meetings held by multidisciplinary teams including social workers and to maintain a copy on residents’ case file. Not Met 11 YA7 To consider seeking advice from speech and language therapists with regard to establishing communication passports for residents. Not Fully Met To offer more opportunities for service users to participate in the day to day running of the home and in the development of the service through consultation with menu planning, service users meetings, representation in recruitment and selection of staff and service user feedback questionnaires. Not Met 8 YA5 9 YA5 10 YA6 12 YA8 Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 51 To improve the frequency of residents’ meetings with written records maintained. Not Met 13 YA8 1) That there is documentary evidence of how residents have been consulted with regards to changing use of communal rooms and facilities 2) That there is documentary evidence as to how the decision to furnish the lounge has been made and that this be investigated to ensure management of behaviours does not impact unnecessarily on the decoration of communal areas of the home 14 YA9 To review, update and expand written risk assessments to ensure that any unnecessary risks to the health and safety of residents are identified and so far as possible eliminated Not Met That risk assessments be completed based on individuals different needs and capabilities to promote a person centred approach to risk management and accurately describe who is at risk, the nature of the risk, existing controls measures and any additional measures, which are required That a system be introduced to link care plans and risk assessments to ensure effective monitoring takes place and to promote a holistic approach to care management. To establish and implement individualised activity programmes for residents taking into account their preferences and needs. Not Fully Met To fully implement monitoring and evaluation systems to ensure that activities which are provided, meet the needs and preferences of residents. Not Met To consider introducing pictorial activity programmes for residents. Not Met 17 YA12 That greater efforts are made to support residents to develop life skills. 15 YA9 16 YA12 Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 52 18 YA14 To continue with attempts to try to ensure that the cost of residents’ annual holiday is provided as part of the basic contract price. Not Met To continue to ensure that any restrictions on choices are negotiated with all individual service users and advocates. Outcomes to be recorded in service user plans and reviewed regularly: for example the decision to not to provide bedroom door keys, front door keys, and the opening of service users mail. If residents cannot give their consent, then staff should consider making decisions in their best interests as in compliance with the Mental Capacity Act 2005. Not Met To consider calculating residents’ ideal weight utilizing a Body Mass Index scoring system and including this on nutritional screening tools. Not Met It is recommended that residents’ supper choices be recorded. Not Fully Met It is recommended that portion sizes are recorded on food charts for residents who are gaining (or losing) weight to allow for monitoring and assessment. Not Met It is recommended that advice be sought from a suitably qualified person such as a dietician with regard to the current menu plan. Not Fully Met 19 YA16 20 YA17 21 YA17 That residents be given the opportunity to be involved in food shopping. To continue to negotiate and obtain consent from residents with regard to same or cross gender personal care. Outcomes to be recorded in individual care plans. If consent cannot be gained then people’s observed preferences should be recorded. Not Met To review the practice of two hourly checks undertaken during the night for service users. (If this level of monitoring is deemed necessary it must be discussed and 22 YA18 Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 53 agreed as part of a multi-disciplinary team with outcomes and guidelines for staff to be documented in individual care plans). Not Met 23 YA19 To improve systems for the recording and monitoring of all health care appointments, for example using health care summary sheets. Not Fully Met It is recommended that all residents be offered opportunities to attend an annual well person clinic for screening for potential complications such as testicular or breast cancer (written records maintained). Not Fully Met To continue to pursue other professionals to assist in the completion of Priority for Health screening tool. Not Fully Met For any service user that has been assessed as lacking capacity to make decisions about their own health and therefore may be admitted to hospital against their wishes a comprehensive care plan and detailed risk assessment should be established. Not Fully Met To ensure that there are systems in place to more carefully monitor residents’ monthly weight checks and that there are guidelines for staff to follow to ensure that weight gain or loss is actioned appropriately. Not Fully Met 24 YA20 It is recommended that the date of opening of all medicine containers are recorded and any balances of medicines carried over onto a new medicine chart in order to check that service users have been given medication as prescribed by a medical practitioner. Not Fully Met That the process for re-ordering prescriptions be carried out in accordance with the homes medication procedure, i.e. requests for repeat prescriptions are generated from the home and checked, with exemptions signed prior to being sent to the pharmacy provider for dispensing so that items can be accurately checked on receipt at the home, with a copy of the original prescription, DS0000069595.V357555.R01.S.doc Version 5.2 Page 54 25 YA20 Hillcrest (Stourbridge) That only the signatures of staff who have medication training are included on the specimen signature list for medication administration That the staff specimen signature list is maintained to be up to date That all handwritten entries on MAR sheets are signed and witnessed by staff trained and competent to do so Ensure that there is a photograph of each resident on their medication records Ensure that MAR sheets contain details of any allergies or record none known That the manager undertakes regular documented medication audits with any remedial actions identified That the medication returns book is consistently signed by staff and the pharmacy 26 YA22 That there is a comprehensive record of all concerns / complaints raised including details of investigations, action taken and outcomes and evidence as to whether the complainant is satisfied with the outcome To ensure that there are full and detailed records maintained of any episodes of challenging behaviour. These should also be dated and signed by the member of staff who has completed the record. Not Fully Met To ensure that behavioural support plans are discussed and ratified by a multi-disciplinary team including psychologists. Progress but Not Fully Met To ensure that all staff understand, read and sign behavioural support plans. Not Met It is recommended that the manager seek the advice of the Local Authority commissioners to determine whether the basic contract fee includes residents’ toiletries. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 55 27 YA23 Appropriate action should then be taken to either reimburse residents or amend contracts and the service user guide. Not Met 28 YA23 That references to use of restraint in the homes documentation be linked to the Mental Capacity Act 2005 relating to restraint and safeguards To establish an up to date written rolling programme of redecoration/maintenance and replacement of furnishings and to forward a copy to the Commission. Not Met To continue to ensure that all exposed pipe work and radiators throughout the Home are guarded or have guaranteed low surface temperatures (or complete written risk assessments if this is deemed unnecessary). Not Met - now made an immediate requirement. To ensure that lockable space is provided in each persons bedroom, with decisions relating to key holding documented in individual service user plans. Not Fully Met To seek advice from a relevant agency to ensure the building and garden areas complies where possible with the Disability Discrimination Act 2005. To action any recommendations made and to forward evidence of outcomes to the Commission. Not Met That the Registered Person ensures formal discussions take place with the CSCI with formal agreement sought before any changes to facilities and rooms take place to ensure any changes made are in the best interests of residents That the environment be improved in the following areas (this is not an exhaustive list): 1) Renovate the gloss paintwork around the skirting boards in the dinning room, which is chipped in places 2) Provide furniture for the communal areas, suitable for the needs of the residents and to create a homely Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 56 29 YA24 30 YA24 31 YA24 domestic environment 3) Repair or replace the 3-piece suite, which has one arm damaged 4) Repair or replace the damaged television cabinet, which was secured to the wall 5) Investigate and rectify the uneven near the centre of the room in the lounge 32 YA26 That the environment be improved in the following areas (this is not an exhaustive list): 1) Replace the light bulb in the light fitment in the overhead mirror the resident’s bedroom on first floor 2) Repair or replace the door hinge to the bedside cabinet in the residents bedroom on first floor 33 YA27 That the environment be improved in the following areas (this is not an exhaustive list): 1) The soiled area in the shower basin under the bathmat be maintained in a clean condition on first floor 2) Refurbish the shower room on the first floor to ensure it is homely and to promote good infection control measures 3) Investigate and rectify the very noisy extractor fan in the toilet on first floor 4) Repair and renovate the walls and flooring in the toilet where walls are stained and there is a hole to the rear of the toilet basin on ground floor 5) Repair or replace the bath in the bathroom on the lower ground floor, which cannot be used due to leaking pipe work 34 YA30 To ensure that the chopping boards in use are in good condition or replaced when they become worn and heavily DS0000069595.V357555.R01.S.doc Version 5.2 Page 57 Hillcrest (Stourbridge) scored – Not Fully Met 35 YA30 To ensure floors are made impermeable in the laundry. To ensure mops are inverted to dry in a well-ventilated area and washed at thermal disinfection temperatures on a daily basis. – Not Met To ensure that there is a more comprehensive cleaning schedule for the laundry. – Not Met 36 YA30 That the environment be improved in the following areas (this is not an exhaustive list): 1) Repair and renovate areas of the laundry walls, which are damaged and flooring which is stained. 2) That infection control policies and guidance be displayed in the laundry to inform and advise staff 3) That the home obtain the most up to date guidance issued by the Department of Health in 2006, to ensure staff practices reflect current good practice guidance 37 YA32 To provide a range of specialist training for staff in autism awareness, person centred planning, challenging behaviour, Mental Capacity Act 2005 and bipolar disorder. Not Met To provide staff with nutritional awareness training. To provide staff with training in risk assessment. 39 YA33 1) To carry out a review of residents’ dependency levels and staffing ratios in order to ensure that there are sufficient staff on duty to meet residents’ needs and to forward a copy of the staffing proposals to the Commission. Not Fully Met To consider introducing a structured time for handover on the current duty rota. Not Met 38 YA32 Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 58 To employ male staff in order to reflect the gender composition of the resident group. Not Met 40 YA33 The registered person is required to demonstrate compliance with responsibilities for the health & safety of employees under the Management of Health & Safety Regs 1999 Reg 3 and to seek advice from the Dudley Directorate of the Urban Environment (EHO) and review the risk assessment in accordance with advice received, especially relating to risks posed from residents displaying physically abusive / violent behaviours. To complete audit of existing staff personal files and replace missing information as required by the Care Homes Regulations 2001, Regulation 19 and Schedule 2. Not Fully Met 1) That all written references contain evidence of validation of authenticity 2) That one written references must be obtained from the most recent employer / or manager designated to give references 3) Any member of staff who commences employment on a POVA first basis must have a written risk assessment completed (as recommended by the Department of Health) on file with competent named supervisor(s) (also documented on staffing rotas) 4) Contracts of employment should be signed by the employee and employer 5) That all staff personnel files contain a recent photograph of the individual 6) That there is documentary evidence to demonstrate that actions as a result of a disciplinary investigation have been carried out in full 43 YA35 1) To ensure that staff receive full and structured induction training suitable for the work they are to perform, and in order to meet the specialist needs of the residents. A written record must be maintained at the care home. DS0000069595.V357555.R01.S.doc Version 5.2 Page 59 41 YA34 42 YA34 Hillcrest (Stourbridge) Not Fully Met 2) To ensure that all staff receive equal opportunities including disability equality training. Not Met 3) To provide induction and foundation training for staff by an accredited learning disability awards framework (LDAF) provider. Not Fully Met 4) To complete an up to date training needs assessment for the staff team and establish a training and development plan. A copy to be forwarded to the Commission. Not Met 44 YA36 To continue to improve the frequency of supervision sessions for all staff (at least six per annum). Not Met To ensure that all staff receive an annual appraisal. Not Met 45 YA37 That an application is submitted to the Regional Registration Team at the CSCI without further delay to complete the recruitment of the new manager who is competent and skilled to run the home. That the registered person ensures that the manager has sufficient dedicated managerial hours to manage the home, introduce appropriate risk assessments and implement improvements to demonstrate compliance with The Care homes Regulations and NMS, assuring the safety and well being of residents 1) Effective quality assurance and quality monitoring systems based on seeking the views of service users, stakeholders, families and advocates should be implemented. Not Fully Met 2) There should be an annual development plan for the home based on a systematic cycle of planning-actionreview. Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 60 46 YA37 47 YA39 Not Fully Met 48 YA39 1) The use of independent advocates to support residents to complete surveys is strongly recommended, these would also enhance the process 2) That surveys are available for staff to complete, with results collated, actioned, monitored and evaluated 49 YA39 That the homes Annual Quality Assurance Assessments (AQAA) submitted to the CSCI should contain accurate, verified information and fuller details of the supporting evidence of what the home does well and the improvements made To ensure that all events affecting the well being of service users are reported to the CSCI as in compliance with the Care Homes Regulations 2001, Regulation 37. Not Fully Met 1) That there is a policy in place for the use of residents monies and for funding of staff meals 2) That the home obtains a copy of the Mental Capacity Act and devises and implements polices relating to this legislation 3) That all policies, procedures and good practice guidance be signed and dated by the acting manager and /or a representative of the company 4) That there is documentary evidence that all staff have read policies, procedures and good practice guidance 52 YA41 That the broken lock for the filing cabinet used for storing staff recruitment documentation be repaired or replaced to comply with the Data Protection Act 1998 To ensure that all staff listed on the current duty rota have undertaken a fire safety evacuation drill (at least biannually). Not Met 50 YA41 51 YA41 53 YA42 Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 61 To evidence that all agency workers undertaking shifts at the home have been instructed in fire evacuation. Not Met To ensure that there is an annual inspection and service of all gas appliances which are carried out by a CORGI registered gas engineer. Not Met To undertake and implement a written analysis of potential food hazards and develop an assured safe catering system, which is a requirement of Food Safety (General Food Hygiene) Regulations 1995. Partly Met Risk assessments need review and additional assessments must be carried out in respect of service users access to the patio area, kitchen, and uncovered radiators (with reference to the fact that no surface temperatures are monitored). Advice should be sought from Environmental Services. Not Met 54 YA42 1) That there is documentary evidence available to confirm portable electrical items have been tested in compliance with legislation 2) That a five year fixed electrical wiring certificate is available at the home 3) That there is a documented Legionella risk assessment completed by a ‘competent’ person, available at the home, with control measures and evidence of bacteriological water testing 4) That there is a documented asbestos risk assessment completed by a ‘competent’ person 5) That there are documented risk assessments for staff transport 6) That the clinical waste bin is secured at all times 7) That the assessment in place for items in compliance Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 62 with the Control of Substances Hazardous to Health Regs 1999 be reviewed to accurately reflect chemicals, ensure that there are appropriate data sheets and documented risk assessments within the home. 8) That a risk assessment be completed with regards to pest control. 55 YA42 1) That records of fire drills include at what time of day or night the drill took place 2) It is recommended that drills occur at various times of the day and evening in order that the home can be confident appropriate action will be taken in the event of a fire 3) That appropriate signage be displayed throughout the home in compliance with the Smoke Free Regulations 2006 56 YA42 1) That copies of documentation relating the company vehicle used to transport residents and staff be held at the home 2) That a record be maintained within the home of daily/weekly checks of the company vehicle to include seatbelts, water, oil, tyres etc to promote good safety management. That the manager is provided with appropriate accredited training relating to: Risk Management The Management of Health & Safety (designated responsible person) Or alternatively appoint accredited consultants to support the home in the above areas 57 YA42 Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 63 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillcrest (Stourbridge) DS0000069595.V357555.R01.S.doc Version 5.2 Page 64 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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