Inspection on 15/05/08 for Inshore Support

This inspection was carried out on 15th May 2008.

CSCI found this care home to be providing an Adequate 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Inshore Support 28/11/06

Inshore Support 23/03/06

Inshore Support 25/10/05

Inshore Support 18/10/04

Inshore Support 21/06/04

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 28/09/2008.

CARE HOME ADULTS 18-65 Inshore Support 110 Wellington Road Bilston Wolverhampton WV14 6AZ Lead Inspector Deborah Sharman Key Unannounced Inspection 15th May 2008 09:30 Inshore Support DS0000044873.V364476.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 Inshore Support DS0000044873.V364476.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. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inshore Support Address 110 Wellington Road Bilston Wolverhampton WV14 6AZ 01902 354481 01384 410429 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) Inshore Support Ltd Manager post vacant Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The administration of prescribed medication by specialised techniques (Percutaneous Endoscopic Gastrostomy) is permitted for one named service user in accordance with agreed training, risk assessments and monitoring standards. 28th November 2006 Date of last inspection Brief Description of the Service: Inshore Support is based in the Bilston area of Wolverhampton and is registered as a care home providing personal care and accommodation for 2 younger adults with learning disabilities. It is part of the Inshore Support Ltd group of housing whose main office has recently relocated to Stourbridge. The home is close to the centre of Bilston with good local amenities. It opened in June 2003 and consists of a two storey terraced property. The two bedrooms are both for single occupancy with bathrooms and toilets close by. There are two lounges, a kitchen and dining area. There is a smallenclosed garden to the rear of the house. Current fees are based on service users assessed needs and are stated in their personal contracts. Fees charged have not been included in brochures available to people who may enquire about the service. This information should be requested directly from 110 Wellington Road or from Inshore Support Ltd. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We carried out this unannounced key inspection between 9.30 am and 6.00 pm. As the inspection visit was unannounced this means that no one associated with the home received prior notification and were therefore unable to prepare. As it was a key inspection the plan was to assess all National Minimum Standards defined by the Commission for Social Care Inspection as ‘key’. These are the National Standards, which significantly affect the experiences of care for people living at the home. Information about the performance of the home was sought and collated in a number of ways. Prior to inspection the Commission for Social Care Inspection was provided with written information and data about the home in the service’s annual return. We also distributed surveys to people who have contact with the home. On the day of inspection we distributed surveys to staff on duty, which we took away with us to analyse, and we also had the opportunity to speak to all staff on duty during the inspection. During the course of the inspection we used a variety of methods to make a judgement about how service users are cared for. Along with all other services inspected this year between 5th and 16th May we carried out a thematic study, which focussed on safeguarding systems and how they meet the needs of people who use the service at 110 Wellington Road. We were provided with set questions to ask and were guided as to what to inspect to help us gather the information needed. The new Acting Manager was available on the day of inspection and together with staff supported the process by answering questions and providing evidence of how care is provided and how the service is managed. We assessed care provided to the two people living at 110 Wellington Road using care documentation, observation and discussion - one was assessed in detail and aspects of care for the second person were sampled. In addition, we viewed a variety of other documentation related to the management of the care home such as training, recruitment, staff supervision, accidents and complaints. We toured the premises and we were able to observe the care of residents during this time. All this information helped to determine a judgement about the quality of care the home provides. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? With a change in management, morale has improved. Service users are not able to communicate their thoughts verbally but staff and surveys tell us that they have become more settled and that ‘things have started to improve’. We had been alerted to concerns about staff skills and experience. We have found that the new acting manager has reorganised systems and conscious that staff need ongoing support to develop, has made training and supervision more available to them to help them to meet service users needs. Training systems now readily identify training staff have done and need and the gaps are being addressed. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 7 Last year service users were not provided with a holiday. This year some holidays are booked and it has been decided to provide two holidays to compensate for the lack of a break last year. What they could do better: Following the dismissal of the previous registered manager, the performance of the service is starting to improve. There are still a number of shortfalls to address. The most significant areas of weakness are in relation to complaints management, protection, and risk and accident management and as these are significant to service users’ well being the service cannot be currently judged as ‘good’. We have been told that the service is not good at listening. Complaints we are aware of have not been managed effectively or openly, although the new acting manager is beginning to improve this. Records show the need for staff to physically ‘restrain’ or redirect service users frequently and the need for this should be reviewed to enable service users to better manage their behaviours. There are a number of bumps and bruises to a resident, the causes of which are not known and have not been reviewed with social workers. Also, the Manager learned during inspection of the need to report incidents of assault between service users under adult protection procedures. In addition there is evidence to suggest that there have been a number of accidents involving a service user that have not been recorded, reviewed or acted upon. Some of these have been caused by environmental hazards that have not been removed reduced or risk assessed. A service user fell backwards down the stairs a month before inspection and a stair gate has recently been put in place in response. This restricts the risk of him accessing and falling down stairs but also restricts freedom of movement for him and the second service user living there. The use of the stair gate should also be reviewed with the Fire Service in case it serves as an obstruction in the event of a fire. No positive action has been taken in response to ‘several’ falls incurred by a service user from 2003 down an internal step into the kitchen. The risks are compounded by a brick breakfast bar an arms width away in front of the step, which in the event of a fall would cause further injury. The nature of these risks and outcomes for the service user cannot be fully quantified as accident records have not been maintained and do not accurately reflect the number and nature of accidents. Further potential risks were identified in relation to bedrails, infection control, the rear gate to the road and hot water in the kitchen and laundry. The Acting Manager has started to address these issues following feedback at inspection and has submitted risk assessments to us, which address some risks in the short term. However, we have some concern about the feasibility of reducing Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 8 risk largely by supervision given current staffing levels. Service users are highly dependent and ‘cannot be left unsupervised’. Staffing levels are provided on a one to one basis to meet care needs but there is no allowance built into the staffing ratio to account for the fact that staff also cook, clean, do laundry and maintain records. 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. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. Quality in this outcome area is good. Although there have not been any new service users admitted to the service, the Acting Manager has a good understanding of how she would support potential new residents in their choice of home. In addition, up to date systems are in place to support new and existing residents to understand their rights and responsibilities whilst living at 110 Wellington Road. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no changes to the service user group and there are currently no vacancies at 110 Wellington Road. The Acting Manager described in detail steps she would take to ensure that, should there be a vacancy, she only admitted someone whose needs could be successfully met. Documentation to support this process is up to date and detailed but we advised that fees charged should be included so when people enquire about the service they have sufficient information upon which to make their decision when considering a care home. As part of her review of the service since taking over three months ago, the new acting manager has reassessed service users needs. She feels that service users needs are now being better met, that care is good and that they Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 11 are safe but said ‘when I arrived I felt service users weren’t getting the care they deserved. I’m not 100 happy that needs are being met now.’ Up to date contracts are available to service users and have been signed on their behalf by their representatives. Alternative formats would help service users to better understand their rights and responsibilities. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is adequate. Service users’ individual care needs are known and are met by staff. There have however been delays in responding to some risks and as a result a service user has had several accidents. Following feedback, these are beginning to be addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are well written, reflect service users’ needs and are based upon principles of respect, inclusion, cooperation and service users abilities and preferences. Care plans have been reviewed and there was some evidence of reviews taking place with placing agencies, although not since 2006. Discussion with staff showed that they are aware of how to meet service users’ needs in accordance with guidance outlined in the written plan of care. Staff also described service users’ known preferences and routines and we observed staff being able to communicate effectively with service users. Staff Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 13 responded to service users’ requests to go out and both were taken out independently whilst we were there. Staff described how one service user likes to make him self a hot drink and we observed him doing this. On arrival we saw that service users were engaged in activities of choice either listening to a favourite singer or watching a favourite video. In the three months she has been working at 110 Wellington Road, the Manager told us she has prioritised getting to know the residents’ needs and reviewing their care plans. She acknowledged that risk assessments which document identified hazards and ways of reducing the risks, are not as she would like them to be. However, we identified much good practice. There are ranges of appropriate risk assessments in place for the service user whose care we looked at in detail, 29 in total. These include recent consideration of risks from moving and handling, nutrition and choking, with behaviours presenting the greatest degree of risk. The new manager has put protocols in place to reduce risks to service users from the busy main road which the home is built on. Staff have signed to indicate that they understand their role in minimising all the identified risks. We identified some significant shortfalls in risk management however that needs urgent attention. A tour of the premises and garden found the side gate to be wide open. The manager felt that service users could release the locking mechanism. This gate, like the front door, leads directly onto the busy A41 road. New protocols designed to minimise this risk have not considered access from the gate. Deprivations of liberty issues associated with such restrictions should be kept under review. Hot water temperature records show us that water temperatures in the kitchen and laundry areas accessible to service users are dangerously high. The documented risk assessment that we saw states hot water ‘will not exceed 43 degrees where outlets are accessible to service users / the public’. We found this not to be the case. Several sources inform us of several accidents incurred by a service user falling down a significantly high internal step to the kitchen. These have not been documented as required by law and are difficult to quantify. We have been told that enquiries have been made but no solutions to this risk identified and as a result no positive action has been taken to reduce the risk in either the short or long term. We identified risks to a service user from bedrails, which are not fitted safely and not maintained. The new Acting Manager has no experience of these issues and staff have not been trained to identify or be aware of the possible risk to service users from bedrails. We asked for immediate action to be taken and the Acting Manager was happy to do this. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 14 The Manager, since she started, has begun to introduce a system of reviewing accidents, incidents and restraints to learn from trends in accidents so action can be taken to protect service users from any risks identified. This will be an ineffective exercise if staff do not accurately report and record all matters. We found accidents to be poorly reported, although this is improving and we received contradictory verbal information about a possible restraint for which we could not find any documented evidence. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 15 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 adequate. Service users’ individual particular dietary needs are known and specialist dietary advice is adhered to well although in the interests of variety a review is very overdue for one person. There is evidence of some activity being offered but the range of activities and opportunities is limited. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information available to us tells us that activity provision has been poor but that it is improving. Activity records from February and March show us that with one or two exceptions the majority of activities were ‘a drive’ for which there didn’t appear to be a purpose. The Acting Manager told us that she prioritised improving activities upon commencing in post but has found it difficult, being new to the area and being unfamiliar with local community resources. Service users now have detailed activity plans, which they will Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 16 benefit from when they are fully operational. We would advise the service to ensure it considers the age appropriateness of activities on offer. We could evidence contact with family including how the service user was supported to deliver a Mothers Day card. Staff know family and friends’ significant birthdays and anniversaries so they can provide service users with support to remember these special occasions. Staff told us that there is sufficient money made available to them to purchase food and petrol but are appreciative that the amounts are to be reviewed with recent increases in prices for these commodities. One service user has complex dietary needs. Staff are aware of these and are managing them well adhering to advice given initially by a dietician. Records are kept which help them to evidence adherence to the strict dietary regime. However these records highlighted the monotony of the menu for this service user who has to have a restricted diet. Noting that the dietician’s menu programme was last devised in 2003, we advised that this be reviewed with a dietician with the aim of trying to increase a variety in recipes that will still meet the dietary need. The Manager agreed and said that staff had started to raise the need for this. We observed the availability of specialist foods required by the service user and how his dietary restrictions are not affecting the other service user who eats different meals. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. Service users’ personal care and health needs are known and acted upon by staff. Medical attention has been sought when there have been changes in health. Routine screening is provided to maximise service users’ health ensuring any changes are detected early. Medication is generally managed well ensuring that service users’ health is also promoted by receiving their medications as prescribed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: By looking at a service user’s care in detail we could see that he had been supported to attend a wide range of health appointments both when staff had identified changes in his health condition and for more routine health screening including dental, optical and foot care. This ensures that good health is promoted with changes being identified and responded to promptly. It was positive to see staff acting upon health advice to provide continuity of care for another service user. For example, a nurse advised that dental advice be sought and staff ensured that this happened. Also glasses prescribed by an optician have been obtained. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 18 Service users presented as well groomed on the day of inspection and sight of care records show service users are supported daily with their personal care. Care plans inform staff in detail how to provide personal care in accordance with needs, preferences and abilities. Discussion with a senior staff member told us that staff are aware that one service user, understandably likes personal support from only staff that he knows well and anything else would trigger behaviours. Respect for this shows a good understanding of privacy, dignity, equality and diversity issues enabling the service user to have control over the care he receives. All staff who administer medication have been trained to do so safely and the manager reported no errors although we note one was reported to us in December 2007 before her appointment. Service users on grounds of capacity do not administer their own medication and relatives have given signed permission for staff to do so. Inspection of medication stocks and administration records indicate that service users are receiving their medication as prescribed to ensure maximum health and well-being. However a contradiction in prescribing direction needs clarifying in one instance to ensure that the service user receives it as the prescribing medic intended. The medication administration record states take 2 x 5ml twice per day indicating that this has been prescribed for administration on an ongoing basis. Crossreferencing this with the written protocol indicates that this should be taken only on an ‘as required’ basis following monitoring of physical functions. It is being administered on an ‘as required’ basis and as a result of the contradiction we couldn’t be sure that the service user is receiving this medication as intended. Assessment of medication stock shows it to be safely and suitably stored. Regular stock audits have been carried out. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is adequate. People do not always feel listened to and complaints have not been managed openly and transparently. This is poor but there are indications that under the new Acting Manager this is improving. There is a high level of physical intervention and although for the most part this appears to be carried out safely, the causes of the behaviours require further review to seek to minimise the effects of this for service users. Systems to support staff to protect service users could be further developed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s annual return to us declares no complaints. We received an anonymous complaint about the service and passed it to the provider to investigate. We received a response saying this had not been upheld. We have received feedback that people have not felt listened to and that complaints have not been welcomed. We are aware of a number of dissatisfactions that have been communicated to the service verbally and in writing. Other than an anonymous complaint about the security of records made at the time this new manager started in post, there was no evidence that previous complaints have been managed openly and we are aware of the added dissatisfaction that this has caused. The anonymous complaint about the security of staff records was not upheld and on arrival we found these records to be appropriately secured. People know how to complain but must be helped to feel that their concerns are valued and investigated thoroughly and accountably. Written complaints procedures are detailed and pictorial Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 20 versions are available. We have suggested that these are made securely available in public areas of the home, perhaps the entrance to ensure that this information is readily available to service users and visitors. This will enable them to know not only how to make a complaint but what to expect having done so. We also advised the manager to consider including complaints and protection issues in accessible formats on a rolling agenda in service user meetings to enable them to understand and where possible to remember what their rights are. The Manager responded positively to this suggestion. All inspections carried out nationally at the time of this inspection were identified by CSCI for a thematic inspection. For this we were given an additional tool to help us to assess how service users are protected by the service. Staff are recruited safely to ensure they are suitable to work with vulnerable adults. We found that half the staff team and the Acting Manager have received training in abuse and protection. Those staff we spoke to understood whistle blowing and the need to report matters of concern even where this may conflict with the service users wishes or maintaining confidentiality. Staff especially senior staff however must be supported to understand that they must not begin to investigate any allegations with an alleged perpetrator. Managers must also understand that incidents between service users can be defined as assault and must always be reported to Social Services and where necessary the Police so that appropriate decisions can be made to ensure all residents are safeguarded. Staff and managers must be provided with a copy of Wolverhampton’s Multi agency Safeguarding policy and procedures in order to fully know what is expected of them in given circumstances. Using our thematic probe tool we assessed the company adult abuse policy and found shortfalls. CSCI was not included as an agency to report allegations to (added since inspection) and roles and contact numbers of appropriate agencies are defined and provided in easy read copies but not those aimed at staff and managers. The Manager said she would find this useful. The physical intervention policy is insufficient although practice is better developed and is based on good practice identified in national guidelines. We advised the manager to obtain copies of guidance issued by both the British Institute of Learning Disabilities and the Department of Health. This will help with the appropriate development of policies to support staff knowledge, training and accountability. Staff reported feeling confident managing behaviours that challenge, as they feel sufficiently trained. Records show staff to comply with good practice by avoiding known triggers and diffusing incidents as far as possible often successfully. However, physical interventions are taking place very frequently and this is accepted as ‘normal’. The need that the behaviours are fulfilling for service users should be reviewed with a specialist as they place limitations on service users opportunities. Recent increases in behaviours are being Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 21 addressed by a psychiatrist for one service user with a review of medication but psychology or behavioural nurse support would be of benefit to both service users. Records of physical interventions where service users have been control walked or physically assisted to calm provide no concern (other than frequency i.e. 36 interventions in 2007 and 2008 to date for one service user) and demonstrate compliance with least restrictive options and are time limited. We could find no documented evidence of a restraint for one service user and we received contradictory information about whether this had taken place. The manager should look into this further. For the service user whose care we looked at in detail, records show staff to be managing daily behaviours without the need for physical intervention (except possibly on one undocumented occasion which the manager is to investigate). Staff meeting minutes show the new manager urging staff to record bumps and bruises on a body map and there are a number of entries for this service user all but one of which are recorded as ‘cause unknown’. Given the level of supervision this service user requires, this is a concern and although there appear to be no injuries after 2.3.08, we advised the Manager to report these without delay to Social Services and that we would consider doing this under our procedures. Shortfalls in the management of bedrails were identified and this does not seek to protect the service user for whom they are used. This is discussed more fully under the ‘Management’ Standards later in this report. Financial records robustly account for expenditure made on service users behalf and staff understood systems in place to protect service users financial interests. Quality assurance systems are not adequately addressing potential safeguarding matters to identify and learn from matters arising. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 22 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, 30. Quality in this outcome area is adequate. The environment whilst domestic in style does not fully meet the needs of service users e.g. the close proximity of a dangerous road and stairs and steps, which are trip hazards. One service user has had several undocumented accidents. Actions being taken now to protect service users place restrictions on their liberties and freedoms within the premises as a result of their unsuitability. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises are domestic and unobtrusive in style, blending into the local community. Some action has been taken to adapt the environment to meet the needs of those whose behaviours challenge for example windows are reinforced with Perspex and the television set is guarded. Communal and personal space is a little bare as a result of behaviours. It is difficult for example to hang pictures, which may be thrown. However, there are creative ways around this by screwing picture frames to the wall or by providing murals Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 23 on walls or a more creative use of colour in decorating. New carpet has been provided in the hall and stairs and wardrobe doors broken since at least November 2007 have been replaced and broken again. With the exception of a shower mat in the ground floor bathroom, which was unacceptably congealed, the premises are kept clean and are odour free. We identified the need to improve some infection control practices. Personal protective equipment is available but we found a used incontinence pad discarded unwrapped in an open basket in the ground floor bathroom. Upon request this was removed to the bin outside. This was found not to be a clinical waste bin although they are available. The manager took corrective action at the time. Similarly as a result of washing machines not being fitted with a sluice facility we asked staff how they would sluice bodily waste. The response did not comply with good infection control practice and would put staff and service users at risk of cross infection and potential ill health. We looked at guidance available on this matter for staff and found shortfalls. Guidance in policy tells staff to ‘rinse body fluids’ but doesn’t detail how or where. An adjustment has since inspection been made to the policy. The Acting Manager should ensure that all staff are aware of this and in addition we advised that the service seeks the support of Wolverhampton’s Infection Control Nurse. A number of concerns about the environment and how it meets the needs of service users have been discussed already in relation to risk management earlier in this report under National Minimum Standard 9, ‘Individual Needs and Choices’. The issues will not be repeated here but in summary relate to stairs, steps, access to the main road and hot water risks controlled by limiting free access around the premises. The provision of additional staff and additional supervision could negate the need for these restrictions. One to one support is provided but with no spare capacity to account for when staff need to cook, clean and do paper work etc. On visiting a service user’s bedroom we found one bedrail to be fitted. It appeared to be fitted very low as the divan is deep and we were concerned about the potential for the service user to roll over it, negating the reason for its use. Furthermore the bedrail was in use without a protective bumper, without risk assessment to account for its use or safety and without any maintenance checks being carried out to ensure its fitness for purpose. Staff are not trained in the safe use and maintenance of bedrails and the manager, new to this home acknowledged her inexperience in this area. We advised the manager to obtain a copy of The Medicines and Healthcare Regulatory Agency’s guidance and to take immediate corrective action. We have strongly advised the Acting Manager to seek the advice of Environmental Health Officers and perhaps more relevant to service users, advice from Occupational Therapists about the limitations and risks from Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 24 stairs, steps and bedrails within the premises. The views of the Fire Service must be sought about the use of a stair gate at the bottom of the stairs. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. Quality in this outcome area is adequate. Staff feel well supported and feel that training opportunities have substantially improved. They feel confident in their abilities to meet service users needs. Staff are recruited safely but are working long hours as a result of current staff shortages. There is little scope within staffing ratios to account for tasks they are responsible for in addition to the supervision of service users and this may compromise service users safety at times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided to us in October 2007 identified concerns about staff competence and suitability. We were told that the service needs to provide sufficient staff with the right skills and experience to match the needs of service users and from another source, that some staff had not been suitable at all. On arrival in post the new manager identified shortfalls in staff training and supervision and has taken steps to address this. Staff spoke positively about training opportunities recently and the support available to them including Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 26 regular supervision. Senior staff said that through providing supervision, the manager has taught them how to supervise staff. Records show staff to have been recruited safely and to have had regular supervision since February 2008. The manager sees this as an on going process and recognises the need to support staff to develop further. A staff member said that epilepsy training would be welcomed to help them to meet a service user’s needs. The manager feels there are still some team issues to resolve but generally information from a range of sources indicates that things are now settling down and that all parties are happier. We looked at staffing levels. Currently the service is short of two team members (equating to 70 hours per week) as a result of staff having left and a long term sickness absence. This is a significant percentage for a small team to manage and the manager reported having to cancel a staff meeting as a result, as there was insufficient staff to supervise service users and attend a meeting. There are a range of options available to cover shifts and perusal of rotas showed that two staff are always on duty, providing one to one care support but that staff are often working long shifts to achieve this. This has the potential to affect the health and welfare of staff and service users and should be closely assessed and monitored. The number of accidents and injuries with an unknown cause are of concern given the level of supervision that these service users require. This is either indicative of the quality of the supervision or staffing levels given that the one to one staffing provided is diluted by a range of other tasks required of multi functional workers e.g. cooking, cleaning, laundry and general administration. This should be reviewed to ensure that staffing levels are always safe and are meeting service users needs. New control measures put in place in response to risks identified at this inspection are based upon the need for close supervision. The service should review how sustainable this is. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is adequate. Since we last inspected, the management of the home has deteriorated. However action has been taken to address this and currently quality is improving. Many systems are in place to promote service users’ safety but accidents have not been reported openly and systems are not sufficiently in place to learn from these to reduce further risks to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the dismissal of the previous registered manager, an experienced manager has been provided on a temporary basis with the remit of improving standards. She has to divide her time between two neighbouring services but has achieved a lot in a short time and everybody we have spoken to and Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 28 received feedback from are positive about the changes. A staff member with whom we spoke echoed the views of another and said the home is ‘good’ as it is ‘a nice home to work in, service users participate in a lot of activities, are well looked after and well fed and all needs are identified and met’. The Manager feels that care is now good but acknowledges there is still work to do and that service users needs are not being fully met yet. A further person has been appointed to continue her work to manage the service on a permanent basis. She is due to start at the beginning of June, intends to apply to us for registration and will be mentored and supported by the outgoing acting manager. Service maintenance documentation that we requested e.g. gas, electric, fire checks and a range of other safety checks carried out weekly were organised well, were readily accessible and were up to date. One staff meeting has been held since February and minutes evidence the provision to staff of guidance, direction and leadership. Regulation 26 visits which are monthly checks carried out on site by the provider are being carried out and are recorded and an internal quality assurance system is in place. The service failed an external independent quality review (ISO 9000) in December 2007 but passed we were told, in April 2008. We queried the effectiveness of internal quality systems given the decline in standards throughout 2007, lack of action taken in response to incidents and accidents, lack of appropriate reporting and the service’s failure to meet the only requirement (the need for COSHH assessments) issued eighteen months ago at the previous inspection in November 2006. In addition quality systems have not identified the need to report all incidents to us or social services such as physical interventions, a hospital visit following a fall downstairs, unexplained bumps and bruises and an incident between service users. Furthermore, the homes Annual Quality Assurance Assessment or annual return, a self-assessment of performance was very poorly completed when submitted to us in October 2007 and demonstrated little understanding of the quality of service provision, national minimum standards or how it intended to make improvements. The Acting Manager, who had not completed this, explained that the AQAA was completed before AQAA training was provided and that prior to this training, staff and managers had not appreciated its significance. Accident records are not compliant in a number of ways. Firstly the information is not being stored and is not storable in service users or staff individual personal files to comply with data protection. Secondly records do not accurately reflect the number of accidents incurred. This is viewed seriously. There are no entries in records beginning 2003 for when a service user broke his leg, obtained a black eye the day before he fell down the stairs, fell down an external step resulting in grazing the week before inspection or for numerous falls by a service user down an internal step as reported to us by a variety of people. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 29 We identified shortfalls in the safety and maintenance of bedrails, which are discussed more fully under National Minimum Standards 22 and 23, Complaints and Protection. The manager and staff are inexperienced in their safe use and adequate guidance has not been given to them. By the end of May 2008 only one staff member will require training in first aid. It is unknown when either the Environmental Health Department or the Fire Service last visited the service. In response to a service users fall down the stairs, a safety gate has been installed at the bottom. The provider must ensure that this is reviewed with the Fire Service, as it may be a fire safety hazard. The indications are positive and we believe there is the potential to improve. Much work however remains to be done. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 30 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 31 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 YA20 Regulation 13(2) Requirement Steps must be taken to ensure that service users are receiving all medications as prescribed. To achieve this, prescribing directions must be reviewed with a medic where there are contradictions between prescribing direction and written protocol. New requirement arising from this inspection May 2008. Timescale for action 30/06/08 2 YA22 22 Any complaint made under the complaints procedure must be fully investigated. The complainant must be informed within 28 days of the action, if any, that is to be taken. This will ensure that people are and feel listened to. It will also ensure that trends in complaints can be monitored and views of complainants can be learned from to help the service to improve. New requirement arising from this inspection May 2008. 30/06/08 Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 32 3 YA23 13(6) All injuries where the cause is unknown or in any way of concern must be recorded and reported to Social Services. This must include incidents of assault between service users. This action will prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. New requirement arising from this inspection May 2008. 31/05/08 4 YA24 13(4)(a)(c) All parts of the home to which service users have access must as far as reasonably practicable be free from hazards to their safety. (Any unnecessary risks to the health or safety of service users must be identified and so far as possible eliminated.) This will protect service users from the risk of accident and injury. New requirement arising from this inspection May 2008. 31/08/08 5 YA42 13(4)a Risk assessments must be carried out on any hazardous substance stored and/or used within the home. This will help to identify risks to service users from products used and steps to take to minimise these risks including the identification of any alternative less hazardous products. This requirement from November 2006 has not been met. Original date for compliance was 28.2.07 30/06/08 6 YA42 17 (2) Sch 4. All accidents, injuries, incidents must be recorded and reported. DS0000044873.V364476.R01.S.doc 31/05/08 Inshore Support Version 5.2 Page 33 This will ensure matters of concern are managed openly and accountably in accordance with regulation and will ensure that they can be reviewed to reduce the risk of repetition. New requirement arising from this inspection May 2008. 7 YA42 23 (4) The use of stair doors and gates must be reviewed with the fire authority to ensure that they comply with regulation and do not compromise safe evacuation in the event of a fire. New requirement arising from this inspection May 2008. 30/06/08 8 YA42 23(2)(c) Steps must be taken to ensure that all bedrails in use are fitted and maintained safely in accordance with the Medicines and Healthcare Regulatory Agency (MHRA) December 2006 ‘Safe use of Bedrails’ guidance. This will ensure that unnecessary risks to the health or safety of service users are identified and as far as possible eliminated. New requirement arising from this inspection May 2008. 22/05/08 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 The range of weekly fees charged should be stated in the Service Users Guide so that this information is readily available to service users, relatives and all stakeholders. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 34 New recommendation arising from this inspection May 2008. 2 YA17 A dietician should be consulted to review the limited range of menus available to a service user following a restrictive diet. This is to attempt where possible to provide a greater variety of meals and interest without compromising dietary need. New recommendation arising from this inspection May 2008. 3 YA23 A copy of Wolverhampton’s Multi Agency Safeguarding Procedures should be obtained and should be available to managers and staff. New recommendation arising from this inspection May 2008. 4 YA23 The Providers Physical Intervention Policy should be reviewed and improved in line with national guidelines (Department of Health and British Institute of Learning Disabilities) to ensure that sufficient and up to date information is available to managers and staff. New recommendation arising from this inspection May 2008. 5 YA23 Consideration should be given to referring service users to behaviour specialists to attempt to identify the causes of behaviours. This will enable staff to develop plans of care to work towards supporting them to reduce the frequencies of behaviours. New recommendation arising from this inspection May 2008. 6 YA24 Creative ways of personalising the environment particularly bedrooms, safely in accordance with service users preferences and needs should be considered. New recommendation arising from this inspection May 2008. 7 YA30 Steps should be taken to review infection control practice to limit the risk of illness to service users and staff New recommendation arising from this inspection May 2008. 8 YA33 Staffing levels and hours worked by staff should be reviewed to ensure that service users care needs and associated tasks can be met and carried out safely at all times New recommendation arising from this inspection May 2008. Inshore Support DS0000044873.V364476.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. 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