Inspection on 08/11/05 for 76 Holland Street

This inspection was carried out on 8th November 2005.

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

The inspector found 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 36 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

76 Holland Street 13/01/10

76 Holland Street 19/01/09

76 Holland Street 15/01/08

76 Holland Street 07/06/07

76 Holland Street 31/10/06

76 Holland Street 24/04/06

76 Holland Street 06/05/05

76 Holland Street 14/02/05

76 Holland Street 27/07/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Holland Street, 76 Sutton Coldfield West Midlands B72 1RR Lead Inspector Donna Ahern Announced Inspection 8th November 2005 10:00 Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 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 Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 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. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holland Street, 76 Address Sutton Coldfield West Midlands B72 1RR 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) 0121 354 2789 0121 355 0832 Social Care and Health Vacant Care Home 22 Category(ies) of Learning disability (21), Learning disability over registration, with number 65 years of age (1), Physical disability (21) of places Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Additionally to the above minimum staffing levels, at night 2 waking night care staff and a senior on sleeping-in duty Minimum day staffing levels are maintained at: morning - 6 care assistants and 1 senior, afternoon - 6 care assistants and one senior. Where off-site day care is provided for five or more service users, day staff levels can be reduced pro-rata between 09:00am and 4:00pm. That the home is registered for 21 adults under 65 and 1 service user over 65 The service users should all be in need of care for reasons of learning disability with associated physical disabilities Registration category will be 21(LD) (PD), 1 (LD)(E) Care manager hours and ancillary staff should be provided in addition to care hours. A programme for planned maintenance and renewal is implemented by end of April 2004. Details of staffing numbers and deployment must be set out in the home`s Statement of Purpose. By end September 2004 plans are agreed with the NCSC with stated timescales for the future re-provision of this service to ensure standards commensurate with fitness for purpose for the needs of the client group. 3. 4. 5. 6. 7. 8. 9. Date of last inspection Brief Description of the Service: The home is a large two-storey building of modern design and appearance, set within its own grounds, occupying a corner position. The home is located in a residential road in Sutton Coldfield. The gardens at the rear of the home are spacious and secluded. There is parking facilities to the front and rear of the building. The home provides accommodation to 22 adults who have a learning disability; some have additional physical disabilities and behaviour that may challenge. Each resident has a single bedroom. The home is arranged over four units. Each unit has a kitchen and a lounge. Incorporated in the accommodation for residents is a flat, which is occupied by two residents. The inspection raised concerns regarding the homes physical standards. The bathroom facilities require refurbishment and other areas of the home require attention as detailed in the main body of the report. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and involved two inspectors. It took place over one long day. The inspectors met all residents and time was spent observing care practices, interactions and support from staff. A tour of the building was made. Residents care plans and risk assessments were inspected. Staff training records were examined, and a number of Health and Safety records were inspected. The inspectors spoke to the manager and five support workers. An expert by experience Nigel, and his support worker Becky from Sandwell People First were involved in part of the inspection. As a service user Nigel had an expert opinion on what it is like to receive services for people who have a Learning Disability. Comments and observations of the expert by experience and CSCI inspectors are referred to in the report as the “inspection team”. This report should be read in conjunction with the report of the visit of 6th May 2005. What the service does well: There is a core team of staff at the home who know the residents needs well. Residents spoken to said they get on well with staff. One resident said she was really pleased and proud to be able to look after her own bedroom and do her own washing. Residents said they liked where the home is located and they are really close to lots of shops, pubs and places to eat out. The inspection team were impressed with some of the work that had been done with a resident who talked about their Person Centred Plan and their plans for the future. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: There is still a lot of work that must be done to make this a safe and comfortable home for the people who live at Holland Street. The manager and staff must improve the care plans that they have developed for each resident. These must tell the staff how to support each person. They must be clear about what help and support each resident needs and what staff must do to support the individual. These must be kept up to date. The home must improve how it says it will help residents reduce some of the risks that they may face in the home or when they go out on an activity or independently access the community. The staff must improve the way that resident’s health needs are recorded monitored and followed up. The Staff must start to do Health Action Plans with each individual. They must also keep up to date the support that residents need with their mobility. The staff and manager must look at how they can enable more of the resident’s to do more things for themselves like cooking and domestic jobs in the home. A lot of work was required to the building to make it a comfortable and safe place for residents. Many of the bedrooms need decorating and painting. The shower room of the first floor must be fixed. The Provider must make sure that Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 7 the bathrooms are suitable for all the residents and that they can safely get in and out of the bath. The Provider must let the people living in the home and CSCI know what the plans are for the future of this home. The Work Place Fire Risk assessment required updating. A fire drill was required so that resident’s and staff know what to do in an emergency situation. Staffing levels continue to be a serious concern. This is a big home where 22 people live, who have a range of needs. Minimum staffing levels of six were not being achieved on a regular basis. Resident’s relatives are also very concerned about staffing levels and the impact that this has on the care of their relative. Medicine management was poor and had not improved to a safe level since the last pharmacist inspection. Staff must do more training so that they have up to date knowledge and skills regarding the residents they support. The required information on staff who work in the home must be available (such as their previous experience and training) and evidence that all of the safety checks on their suitability to work in the home have been carried out before they start to work at the home. So that the provider can demonstrate their commitment to protect residents. It will be good for residents and the development of the home when there is a permanent manager in place. 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. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 No new admissions will be made to the service. The Statement of Purpose and Service User Guide was under further development so that information about the home is available in suitable formats for the people who live at Holland Street. EVIDENCE: The Statement of Purpose and Service User Guide had been reviewed since the previous inspection. The manager was in the process of ensuring that information is provided to residents in a format that is appropriate to their needs. There have been no new admissions to the home since the previous inspection. CSCI were informed that as residents are supported to move onto new living environments the provider will reduce the number of registered beds and no new admissions will be made. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Care plans required development so that a comprehensive plan is in place for each residents that details how their assessed needs and goals will be met. Risk assessments must be developed so that residents are supported to take risks within a risk assessment framework. EVIDENCE: Three residents care plans were sampled. The previous report raised the need for a more comprehensive care plan system to be implemented that detailed residents support needs and how these needs must be met. The care plan format in place was I.S.S (Individual Service Statements). Three I.S.S’s were assessed. One of the sampled I.S.S was very detailed and included input from other professionals including the physiotherapist and Speech and Language therapy. Reviews of the I.S.S had taken place however these must be on a six monthly basis. If there are no changes to the care plan then this must be documented. One of the other I.S.S sampled required the information to be more detailed regarding how the support should be given. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 11 Another I.S.S sampled, had not been reviewed since July 2003 the residents needs had significantly changed and this had not been reflected in the I.S.S. Resident’s documentation must be kept under review. It was positive the manager had implemented a system where the summary of the care plans was kept with resident’s daily notes and this provided some key information in an easy reference format. The inspection team spoke to some of the residents about their care plans. One resident said they were not sure if they had a care plan. One resident spoke about their person centred Plan, which is helping them and their friend to move to a new home in the near future. The resident said that they had also just started a new job working at a charity shop, which they were really pleased about. The resident kept their plan in their own bedroom. It was really positive to hear how a Person Centred Plan was moving forward and the resident getting the opportunity to move out from the home with their friend. The manager informed the inspection team that other people have person centred plans and they were working on putting these onto audio and some into video format so that they are more appropriate for the individual resident. Social Care and Health senior managers had informed CSCI that they were in the process of reviewing all their care plan documentation and looking at supporting residents to complete plans that are more person centred. Risk assessments were examined and significant development of these were required. Risk assessments must be implement in a number of areas that may pose a risk to individual residents. There were no risk assessments available regarding resident who are supported to develop their independence skills such as cooking and washing and household tasks. Limited risk assessments were in place for residents who access the community independently. Some of the “support protocols” that had been developed for individual residents had some good information but required further development so that there is evidence that the safeguards in place are adequate. Support protocols must cross reference to the relevant risk assessments. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Residents who are more independent of staff support are able to take part in activities at home and in the community. The staff must improve opportunities and be able to evidence how they support residents to develop their independent living skills. EVIDENCE: On the ground floor there is a large industrial kitchen where staff prepare and serve meals for the majority of residents. There is also a domestic kitchen, residents were observed accessing this facility. The kitchen had sinks that had been adapted so that they were suitable for residents who use a wheelchair to access. The inspection team spoke to one of the residents who said they eat their meals in the main dining room. They do not do the shopping list or the cooking. The food is delivered to the main kitchen. They said they are given a choice of two meals each mealtime. Another resident said that they would love the opportunity to cook and shop for themselves on a regular basis. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 13 On the first floor, which is referred to, as C wing there is another kitchen, which is used by the six residents who live on this floor. The home refers to this part of the home as the minimum care unit. The previous inspection in May 2005 raised concern about the condition of this facility and questioned whether residents were receiving adequate support to develop their independent living skills. Improvements had been made to the cleanliness and organisation of this facility so that each resident who lives on this wing are supported with their independent living skills. The inspection team spoke to some of the residents who live on this wing. One resident showed some of the inspection team around their kitchen and explained that they write their own shopping list, shop for their own food and cooks their own meals with support from staff. Residents said that they take it in turns to cook for each other every night. The manager informed the inspection team that there were plans in progress for developing the home into four separate units and providing greater opportunities for more residents to be able to live more independent lifestyles. Discussions were taking place with residents about had this could be achieved. The inspection team felt that the phrase “wings” was a very out of date expression and maybe the residents could be involved in discussing alternative ways for naming and identifying the different parts of the building. Many of the residents attend a local day centre or college. One of the residents told the inspection team that they really enjoy going to college but sometimes they are not able to go because ring and ride don’t turn up, as witnessed on the day of the inspection. The inspection team felt that the manager should have a back up plan for when this happens so that the resident isn’t let down. It was good to hear on this occasion the person was supported by a staff member to go Christmas shopping. Some residents said that they enjoy going to Gateway club on a Monday night with support from staff. Residents said that they have good access to a range of shops, pubs and places to eat in Sutton Coldfield Town Centre, which is a short, walk away. Some of the residents live fairly independent lifestyles and come and go as needed. Residents were observed saying goodbye to staff as they left the home and advising staff of their return time. The previous report raised concern about the lack of risk assessments to evident that residents are supported to take risks as part of an independent lifestyle. No progress had been made on the implementation of these. These must be actioned so that the potential risks to residents are identified and appropriate risk assessments and guidelines are implemented to minimize the risk and promote the safety of individual residents. This was of particular importance for residents who access the community independently. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 14 One of the residents told the inspection team that they do not get the opportunity to go out very often, they need a wheelchair to go out and the person said that there is not always have enough staff on duty to take them out. Some residents do not attend day centres during the week or they only attend on a part time basis. The previous inspection raised concern about the lack of activity during the day. There was evidence of some improvement and some residents and staff were engaged in tabletop activities and games. There was the need to look at suitable activities within the home and local community for the residents who required a greater level of staff support. Lots of the residents told the inspection team that they often see there families and some people go home at weekends and other people said that their family visit them. Staff said the families are encouraged to play a big part in peoples lives. The families are involved in fund raising. They are currently trying to get some money to buy a minibus for the home. The inspection team appreciate the reasons for the residents and staff wanting to have their own transport. They felt that some thought could be given to buying smaller vehicles such as people carriers which may be more appropriate and provide more choice for residents and enable people to go out in smaller groups. Some of the residents told the inspection team that they get on well with the other people who live at Holland Street. Some of the residents said that a lot of people live in the home. One said, “Sometimes the home is to noisy” and another resident said, “Some of the people shout and that upsets me I don’t like it. These comments were also raised in the “Service user comment Cards” that residents had completed and returned to the inspection team. The breakfast time was observed on the ground floor dining area. Residents were given good support and a choice of breakfast was provided. A risk assessment and guidelines were required for one resident whose care plan had identified a risk of choking on specific food items. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Improvements must be made to resident’s health care information so that the manager and staff can demonstrate that residents have received the medical and health input they require. Manual handling assessments had not been kept under review and this has the potential to place residents at risk. The medication records did not reflect accurately what had been administered to the service users in all instances, and had the potential to place residents at risk. EVIDENCE: Residents care plans indicated that they are supported to attend a range of healthcare appointments. The way that appointments and the outcome are recorded varied considerably on sampled care plans. Some appointments were recorded on the healthcare log and the detail was cross-referenced to a daily record entry. Other appointments were recorded in with daily entries. On one sampled file the last entry on the health record sheet was March 2004. A letter on file indicated that a review of the person epilepsy took place in January 2005. It was not possible to ascertain the outcome of the review. On another residents file there was a letter detailing an appointment in September 2005 again the appointment or outcome had not been recorded on the healthcare Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 16 log. It was difficult to track health outcomes and the recording systems must be revised. Manual handling risk assessments sampled had not been kept under full review. One assessment was implemented in 2001 and had been reviewed in June 2005. The review stated, “Parts of the mobility risk assessment are still relevant”. The resident’s needs had changed considerably and this was not an adequate review of their needs. Another resident’s mobility needs had been adequately reviewed in June 2005. The manager said that Health Action plans folder had been provided for residents and the staff will now support residents to complete these. A requirement of the previous inspection was to review the needs of residents with additional physical disabilities, including their bedroom layout and their lifting and moving needs. This had been actioned and the beds had been moved so that staff can support from both sides of the bed. The rooms are small and the new layout has presented some additional challenges to the staff when assisting residents. The bedrooms were not adequate to meet the needs of a person with additional physical disabilities, they are cramped and there is no turning space. The manager said as residents move from Holland Street to new homes there will be the opportunity to make some of the bedrooms bigger. Risk assessments required implementing for residents with epilepsy. The support required by residents during the night must be risk assessed and any support required from staff and how this must be given must be documented. The majority of audits undertaken demonstrated that the residents did not routinely receive their prescribed medication. Two members of staff had signed all records of administration, and still mistakes were found. One medicines dose had been increased and staff had signed and witnessed this administration for seven doses before realising that the medicine was not available to administer. These entries were subsequently crossed out. Not all the quantities of medicines received or balances carried over from previous cycles had been recorded so it could not be demonstrated that medicines had been administered correctly. New monthly entries were recorded on the old Medicine Administration Record (MAR) chart instead of a new sheet. This is considered poor practice. The home does not check the prescriptions prior to dispensing. There are no systems in place to check the dispensed medication into the home. The home had more medicines on the premise than was needed to complete the 28 day cycle indicating poor ordering. Medicines were found in the cabinet that had not been recorded on the Medicine Administration Record (MAR) chart. Old medicines were found and there was no clear policy to review the service users medication on a regular basis. All boxed medicines were dated once opened. This confirmed that not all doses of medication had Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 17 been administered. Following a previous serious incident medicine are prepared for administration individually to prevent further mistakes. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Development of the complaints and adult protection policies were required so that the provider can demonstrate that individuals are listened to and their rights and welfare is protected. EVIDENCE: The previous inspection required that some minor additions were required to the Adult Protection Policy and Procedure, so that there is clear information and relevant contact details available for staff to access and follow in the event of abuse being suspected or disclosed. The complaints log had been developed so that the outcome of complaints and any follow up is clearly documented. Some complaints were still under investigation and CSCI must be informed of the outcome. The organisation complaints department had changed, contact details on the complaint forms required amending so that the correct information is available to complainants. There was a pictorial complaint procedure in the complaint folder in the office, which was more appropriate for many of the people who live at Holland Street. The inspection team could not see anywhere in the main part of the home information on display telling people how they can complain. It was positive to read on the complaints log and regulation 37 log that concerns raised by residents about staff had been listened to recorded and followed up on. Residents told the inspection team that they think complaints are taken seriously. Residents asked said they felt confident talking to the staff if they Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 19 are unhappy. One resident said they were fed up complaining about things and that they are told, “there isn’t enough staff or money”. CSCI received an anonymous complaint in June 2005 regarding not enough staff on duty to support residents. The complaint was forwarded to the provider to investigate. The outcome of the complaint was upheld and the provider made a commitment to ensure minimum staffing levels of six staff on duty would be maintained. As raised under standard 33, staffing levels at the home remain a serious concern. Concern was raised regarding receipts on resident’s files indicating that residents own money was used to pay for repairs to a specialist bed and proposals for a resident to purchase essential equipment. There must be clear guidelines in place regarding how resident’s money is used. Residents must not pay for items that are deemed essential items. When a resident has made a choice to purchase items of furniture from their own money details of how this decision was arrived at must be clearly documented. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is not suitable for the purpose of achieving its stated aims and objectives. Many parts of the home required redecoration and were not well maintained and comfortable for residents. EVIDENCE: The previous inspection raised a number of concerns about the physical standards within the home. Particular concern was raised about the condition of the bathrooms. It was positive to see that some improvements had been made. Communal areas looked more homely and pictures had been hung on the walls and there were lots of photographs of resident’s social events. Minor repairs had been done to the bathrooms including repairs to ceiling panels and wall tiles. A thorough clean of the kitchen on the first floor used by residents who live more independently had been undertaken and equipment had been reorganised so that it was more accessible to residents. One shower remained out of order and in need of repair. Painting and decorating was required throughout the home. Areas where there was damp coming through required attention to the plaster and décor. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 21 Some of the residents were happy for their rooms to be seen and it was lovely to see how personalised the rooms had been made. There was concern about the lack of space in the rooms that accommodate residents with additional physical disabilities. This matter is also raised under standard 18. Some of the rooms have dividing partitions and not a stud wall. The sound proofing between rooms was inadequate and it was felt that they compromise the privacy of the residents who occupy these rooms. Staff raised some concern stating that since some bedrooms were reorganised to accommodate lifting and handling needs some residents now have difficulty accessing their personal items and difficulties seeing their television. This must be reviewed. The inspection team felt it was not acceptable that the people who use wheelchairs were not able to access the upstairs of the building. People should be able to access everywhere in their home. People may have friends they want to see upstairs. The building discriminates against people who use a wheelchair. A condition of the homes registration was that by the end of September 2004 plans would be forwarded to CSCI for the future reprovision of this service to ensure standards commensurate with fitness for purpose for the needs of the client group. As previously reported these timescales had long passed. CSCI met formally with the provider in September 2005. An action plan was forwarded to CSCI, which stated that the provider would forward a planned maintenance programme and a redevelopment plan for all Learning Disabilities homes by 21/11/05. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, and 35 Staffing levels required review so that adequate staff are on duty to meet resident’s needs and to meet the staffing conditions of registration. Information held in the home on staff and recruitment practices are not adequate and fail to demonstrate that the home was safeguarding residents. Staff required training updates so that they have the required skills and knowledge to meet resident’s needs. EVIDENCE: Staffing levels are a condition of registration. The home is required to have six support workers and a senior on each shift. At night there is two waking night staff on duty. The required level of staff was on duty at the time of the inspection. Examination of the rota indicated that the home continues to experience difficulty meeting these levels. Staffing levels for the month of October 2005 were analysed and the outcome was of serious concern. Out of sixty-two shifts, on forty-two shifts the staffing levels were below the required six on shift and on seven of these shifts staffing levels were as low as four staff on shift. The deputy manager stated that “excessive sickness” and “unavailability of agency staff” were the reasons for the levels being so poor. This was unacceptable a number of residents have complex health needs and additional Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 23 physical disabilities. The layout of the home is vast over two floors and four different units. Staffing levels so low and in breach of the minimum required level has the potential to place residents at risk. Three of the comment cards received from relatives raised concern about staffing levels in the home. There was a 105 care hours vacant and the manager stated that vacant posts were being appointed to. The home must continue to notify CSCI when they drop below the minimum staffing level. A letter of serious concern was sent to the provider. A formal response was required to these concerns. Staff recruitment files were not assessed at this inspection the previous requirements in respect of these were carried over to this inspection. Staff training files required some development and reorganising so that completed training dates, the duration of the training, training provider and when updates are required are clearly documented. Since the last inspection training had taken place on Fire Safety and Manual Handling. Some training updates and refreshers were required so that staff have the up to date knowledge and skills to support resident’s needs. Training was required in, food hygiene; manual handling, epilepsy, adult protection, and person centred planning, disability equality training and anti-racism. A training needs assessment must be carried out for the staff team and details of this must be forwarded to CSCI as previously requested. Attention was required to the frequency of formal supervision of staff. Sampled records indicated that sessions take place on an infrequent basis. Staff must receive a minimum of six supervisions a year so that they receive the support and supervision they need to carry out their job. Interactions between residents and staff were generally positive. Staff was seen to make time to talk to residents on a one to one. One of the residents told the inspection team that he likes some of the staff and some staff he put up with. Some residents said they liked the staff. The manager said that residents are involved with the recruitment of staff. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Further development of Health and Safety practices and record keeping was required to ensure that resident’s welfare and safety is protected. EVIDENCE: The manager’s post at Holland Street had been vacant for a protracted period. An acting manager has been in post since April 2005 and a temporary deputy had transferred on a temporary basis from another Social Care and Health home. The Recruitment process for a permanent manager was in the final stages. The proposed manager has an interview with CSCI in November 2005. There was evidence of some improvements in the homes record keeping since the previous inspection. Throughout the inspection process the manager presented as open, positive and inclusive and welcomed the inspection process. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 25 A number of Health and Safety records were examined. An immediate requirement was made to undertake a Fire drill every six months and a record of the drill the outcome and any action required must be documented. The Work Place Fire risk assessment required review. The fire alarm system must be tested weekly as some of the tests had been missed. Risk assessments regarding residents, their health care records and residents care plans required further development so that the provider can evidence that their needs and changing needs are kept under review. Where the provider is an organisation they are required to nominate someone to carry out unannounced visits to the home and carry out interviews with residents, their representatives and persons working at the home. A written report on the conduct of the home must be produced and a copy available at the home for inspection and a copy sent to CSCI. Examination of the reports available in the home indicated that such visits had not been undertaken monthly as required. The owner’s representative must evidence that such visits have been undertaken in accordance with the regulations and that they are fulfilling their responsibility to oversee the overall management of the home. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 2 X X X X X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 1 2 2 1 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holland Street, 76 Score 2 1 1 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 2 DS0000033648.V256041.R01.S.doc Version 5.0 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (1) (2) Requirement Care plans required further development.They must be clear and specific about the support required by residents and kept under review. Risk assessments must be further developed. They must be clear and specific about what the risks are. They must be kept under review. Residents must be offered a choice of activities.The range and choice of activites must be kept under review. The Provider must promote opportunities for residents to develop their independent living skills. A risk assessment and guidelines must be implemented for the resident at risk of choking on specific food items. Manual handling risk assessments required further development. They must be kept under review. Residents support during the night must be risk assessed. Health care recording must be DS0000033648.V256041.R01.S.doc Timescale for action 28/02/06 2 YA9 13 (4) a, b, c 31/12/05 3 YA12 16 (2) (m) 31/12/05 4 YA11 12 (1) (a) 15 (1) 13 (4) 12 (1) a, b 31/12/05 5 YA17 30/11/05 6 YA18 13 (5) 31/12/05 7 8 YA18 YA19 13 (4) a, b,c 12 (1) a 31/12/05 30/11/05 Page 28 Holland Street, 76 Version 5.0 9 10 11 YA19 YA19 YA20 12 (1) a 13 (4) 12 (1) a 13(2) improved. (Previous timescale 30/06/05). Risk assessments were required 30/11/05 for residents with epilepsy. Health Action Plans must be 28/02/05 implemented for all residents. All prescriptions must be seen 09/12/05 prior to dispensing, checked and a system installed to check the dispensed medication and the Medicine Administration Record (MAR) chart once received into the home. 16/11/05 12 YA20 13 YA20 14 15 YA20 YA20 16 17 YA20 YA20 18 YA20 13(2)17(1)a The quantity of medicines Sch3(3)i received into the home or the balances carried over from previous cycles must be accurately recorded to enable audits to take place to demonstrate that the medicines have been administered as prescribed. 13(2) Regular staff drug audits before and after a drug round must be undertaken by the manager to demonstrate staff competence in medicine management. Appropriate action must be taken when discrepancies are found. 13(2) There must be enough medication on the premise for the 28-day cycle only. 13(2)17(1)a A new Medicine Administration Sch3(3)i Record (MAR) chart must be written (or printed) for each 28 day cycle. 13(2) All medicines that are no longer required must be returned to the pharmacy for destruction. 13(2) A new monitored dosage system for the administration of medicines must be installed. Liaison with the pharmacist is required to achieve this. 13(2) Improved storage facilities must be installed to house any DS0000033648.V256041.R01.S.doc 09/12/05 16/11/05 16/11/05 16/11/05 09/12/05 09/12/05 Page 29 Holland Street, 76 Version 5.0 new system implemented. 19 YA23 13 (6) Minor development of the Adult Protection Procedure was required (Previous timescale 1/4/05). Guidelines must be in place for how residents money is spent on their behalf. The provider must be able to evidence how decisions to spend residents money has been arrived at. The ceiling on C wing was damp and peeling and required repainting. Paintwork throughout the home required attention. The damp on the wall in the hallway required attention and the paper repaired. The showere room on D wing required repair. (Previous timescale 10/06/05). The home must review the use of electrical sockets and the use of extension leads in residents bedrooms.(Previous timescale All bedrooms must be audited against the National Minimum Standards For Younger Adults. Any shortfal in furniture and fittings must be provided. (Previous timescale 1/4/05). Carpets required cleaning. (Previous timescale 30/06/05). Redevelopment plans for the service must be forwarded to CSCI. (Previous requirement September 2004). A planned maintenance and renewal Programme for the building was required. Staffing levels must be reviewed. The minimum staffing levels must be maintained. Vacant posts must be appointed to. DS0000033648.V256041.R01.S.doc 31/12/05 20 YA23 13 (6) 31/12/05 21 22 23 24 25 YA24 YA24 YA24 YA24 YA24 23 (2) (d) 23 (2) (d) 23 (2) (d) 23 (2) (d) 13 (4) a 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 26 YA25 16 (2) c 31/12/05 27 28 YA24 YA24 23 (2) d 23 (1) a (2)(a) 23 (2) (b) 18 (1) a 31/12/05 21/11/05 29 30 YA24 YA33 21/11/05 31/12/05 31 YA33 18 (1) a 28/02/06 Holland Street, 76 Version 5.0 Page 30 32 YA34 7,9,19 Sch 2 33 YA35 18 (1) (a, c) 34 35 36 YA36 YA42 YA43 18 (2) 23 (4) 13 (4) 26 The home must have on each staff file all of the information as detailed in schedule 2 of the National Minimum Standards for Younger Adults. Not assessed previous requirement carried over. Staff must receive training in Challenging Behaviour. Adult Protection. First Aid Manual Handling Epilepsy Person Centred Planning.A training plan and matrix was required. Staff must receive regular supervision at least six per year with records kept. The work place Fire Risk assessment required review. A representative from Social care and Health must visit the home unannounced on a monthly basis. Reports of the visits must be available in the home. Copies of the report must be forwarded to CSCI. (Previous requirement 15/3/05). 28/02/06 28/02/06 31/12/05 30/11/05 31/12/05 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 YA20 Good Practice Recommendations One person must take full responsibility for the administration and recording of medicines at any one time. It is recommended that only one person sign the Medicine Administration Record (MAR) chart. Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 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 Holland Street, 76 DS0000033648.V256041.R01.S.doc Version 5.0 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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