Inspection on 19/12/06 for Kathleen House

This inspection was carried out on 19th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kathleen House 27/10/08

Kathleen House 07/11/07

Kathleen House 10/11/05

Kathleen House 21/07/05

Kathleen House 10/01/05

Kathleen House 06/04/04

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 Kathleen House 59-61 Addison Road Brierley Hill Dudley West Midlands DY5 3RR Lead Inspector Mrs Jean Edwards Key Unannounced Inspection 19th December 2006 09:30 Kathleen House DS0000024949.V322203.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 Kathleen House DS0000024949.V322203.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. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kathleen House Address 59-61 Addison Road Brierley Hill Dudley West Midlands DY5 3RR 01384 70187 F/P01384 70187 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) Mr R Murray Mr P Murray Mrs Dawn Welding Care Home 15 Category(ies) of Learning disability (15), Physical disability (15) registration, with number of places Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 15 PD and up to 15 LD, not exceeding the total number registered for. No service users who are wheelchair users be accommodated at 59a Addison Road. Existing service users using the service over the age of 65 years may continue to be accommodated for short respite, for as long as the home can demonstrate it can meet the service users assessed needs, with a maximum of 5 LD(E) at any one time. 10th November 2005 Date of last inspection Brief Description of the Service: Kathleen House is a purpose built Home, opened in 1995. It provides residential care on a short-term respite basis for up to fifteen younger adults with learning/physical disabilities, at any one time. The Home comprises three self-contained bungalows, each accommodating up to five people. Located in a residential area, it blends in well and has easy access to local amenities and public transport with links to towns such as Brierley Hill, Dudley and the Merry Hill shopping centre. Externally the property is well maintained, with car parking at the frontage and space between the bungalows. To the sides and rear of the premises are well-maintained gardens, with small patios, lawned areas, mature trees and shrubs. The interiors of the bungalows are domestic in style, promoting a homely environment and maintained to high standards. Beds at the Home are block purchased by Dudley Social Services Department. In excess of one hundred and forty guests use the service. There is a stable staff team, with leadership provided by the Registered Manager, who has been in post since the Home opened. The service has been extended with an additional bungalow, which was registered on 13th February 2004, to provide up to 15 places. Additional staff were recruited, inducted and trained prior to the new registration. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This first key unannounced inspection for 2006 - 7 has been conducted by an Inspector from the Commission for Social Care Inspection and has taken place over one weekday 9:30 a.m. and 5:40 p.m. The purpose of the inspection visit has been to assess progress towards meeting the Care Homes Regulations 2001 and National Minimum Standards for Younger Adults. The range of inspection methods used to make judgements and obtain evidence includes discussions with the registered manager, day care officer, seniors and other staff on duty. There has been contact with professionals associated with the home and discussions and observations with the majority of guests visiting the home for short respite stays, some of whom do not have verbal communication skills. A number of records and documents have been examined, including responses to complaints. Other information was gathered prior to the inspection visit, from reports from the home and a pre inspection questionnaire submitted by the home. Fifteen service user surveys were sent to the home by the CSCI and an analysis of the ten survey forms returned is contained throughout this report. Comments have been generally very positive about the home and staff. What the service does well: Information about the home and the service it provides is readily available on the premises, though now needs updating. Guests and families are able to visit the home prior to staying and can have as many short visits for meals or overnight stays as they feel they need before deciding to stay for longer visits. The Manager and staff provide advice and support to everyone, including their families, using the service provided by this home. Although the guests only visit for short periods of time, they are encouraged by staff to treat Kathleen House as their own home and to be as independent as they wish. Guests are able to make their own choices and take an active part in the running of the home. The manager and staff make sure that each guest and as appropriate their relatives are involved in the plan of how their care is to be provided, each person has a written personal profile. The home also has good relationships with local GPs and other community and health care services, which provide support for guests using the service provided by Kathleen House. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 6 All guests are generally able to spend their leisure time either in the home with a range of stimulating activities supported by staff or pursuing their individual interests in the wider community, decisions which are fully supported. Kathleen House is tidy, homely and comfortable. The home does not employ domestic staff and everyone is involved in cleaning duties. The bungalows and grounds are maintained to generally good standards. There is continued evidence of the volunteer gardeners skills and attention; the grounds and gardens look well maintained. Kathleen House continues to have a stable staff team; some people have worked at the home for a long time and know the majority of guests well. They are caring, committed and flexible, often willing to work extra shifts, especially to support guests with outings and trips. Members of staff continue to demonstrate a dedicated approach to their work; they clearly know guests’ likes and dislikes and how to meet their needs. They readily answer questions in an open and honest manner. A guest states, I like it, the staff are brilliant Comments from the CSCI service user survey about what is good about the home, and observations during the visit are: the nice staff never forget my birthday, good friends and the pub on a Friday, feels good; I am made to feel welcome at all times when I arrive. I can listen to my music in my room at all times, seeing my friends and helping to do things, i.e. making my lunch; and the staff are always friendly This inspection was conducted with full co-operation of the registered manager, trainee manager, staff and guests. The atmosphere through out the inspection has been relaxed and friendly. The Inspector would like to thank the manager, staff, and guests for their hospitality during this inspection visit. What has improved since the last inspection? The new registered manager has continued the system where members of staff move to work in a different bungalow every six weeks so that they all get to know all of the guests over a period of time. This is important because the home offers a respite service to more than 180 people from the Dudley Metropolitan Borough. There is also a weekly auditing process in place, with an award for the team and bungalow achieving the best performance over a number of areas. A guest says, the place is always clean, I like helping The home has made a number of improvements to comply more fully with health and safety legislation. For example risk assessments relating to the environment and guests activities have been reviewed and expanded, with detailed controls measures to minimise any hazards. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 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 Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is a statement of purpose and service user guide in a standard format, which provides information about the service to guests and families. Insufficient progress has been made to provide contracts/terms and conditions of occupancy for each person’s file this means that guests and their advocates do not have sufficient information regarding their rights and entitlements. All assessments of prospective guests are conducted sensitively and professionally, with all relevant information obtained prior to agreeing admissions to use the respite service provided. EVIDENCE: Kathleen House has a statement of purpose, which sets out the aims and objectives of the home, and there is a service user guide, which provides basic information about the service and the specialist respite care this home offers. The information is made available to guests and families in a standard written format. The alternative formats have not yet been developed and some information is out of date, such as the new registered manager in post. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 10 There is evidence from records and discussions that admissions are only agreed to the home after a full needs assessment has been undertaken. The registered manager and a skilled and experienced member of staff always undertake the assessments. The assessments are conducted professionally and sensitively and involve the prospective guest, and their family or representative, where appropriate. All beds are block purchased by Dudley Social Services and the registered manager insists on receiving a summary of the care management assessment and a copy of the care plan to address identified needs. There are generally regular multi-disciplinary reassessments of guests needs in conjunction with other agencies. Although the home has developed temporary contracts / agreements so that guests have with clear terms and conditions for their respite stays. From the sample of guests case files examined it is evident that not everyone has a statement of terms and conditions/Contract relating to their admission to the home. The existing document does not provide sufficient information about what people who stay at the home can expect to receive, or the fee levels. This is a particular omission for the guest staying at Kathleen House for an extended visit. There are nine guests at home during the morning of the inspection and an additional six guests are admitted in the evening, meaning the home is fully occupied. It is stated that the home usually operates with 90 - 100 occupancy. The number of approximately 180 guests and families across the Dudley Borough, supported by this home means the home is fully subscribed and has reached capacity. The registered manager intends to discuss the implications with the Service Manager for people with Learning Disabilities in Dudley MBC. The home does not currently have sufficient management and senior staffing capacity to ensure all guests have at least an annual review and reassessment of their needs. Staff are generally knowledgeable about the needs of guests staying at any one time. However with the increased numbers of guests using the service and emphasis on individual choice the staffing levels are not always sufficient for in house activities and interaction with the local community supported from the home. There are staff training needs identified to equip the staff to meet specific needs and provide person centred support and care. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although there is a clear care planning system, with personal profiles and risk assessments, these are not always updated and reviewed and are not always adequate to provide staff with the information they need to satisfactorily meet guests needs. EVIDENCE: The home uses the term personal profile to refer to the care plan because of the short-term nature of the service provided by this home. From a sample of case files examined there is satisfactory evidence that each guest has a comprehensive personal profile in place. There is basic information available however the documentation is not currently in a range of formats to meet the language and communication needs of the guests. The home has not yet adopted a person centred approach to the care and support for each guest. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 12 The registered manager has put systems in place to ensure that signature sheets are completed on admission with all guests / representatives to indicate their agreement with their personal profile, for example for medication and use of any measures such as bedrails. There is a comprehensive risk assessment system in place for each guest. These include activities within the home environment and on outside activities, where the home has a duty of care, however not all of the sample of guests risk assessments have been regularly reviewed. The personal profiles generally contain a summary including a pen picture of the person. Preferred name, personal care, preferred daily routines; times of rising and retiring, sleeping patterns, such as number of pillows, lights and night checks are well documented. Details of likes, dislikes, favourite foods and preferred activities and friendships are also recorded. Personal profiles give staff guidance about each persons preferred routines for personal care and bedtimes. The registered manager states that a key worker system had been used but was not effective because of the large number of guests using the service and the transient nature of the visits. However the lack of named workers for each guest, even for each visit poses the risk that not all of their needs will be known and will not be satisfactorily met. There is evidence from case records and discussions that the home participates in reviews held by other agencies such as day care services or with community healthcare professionals. It has previously been agreed that a practical approach to reviews initiated by the home, is to hold an annual review for each guest as a minimum, as there were in excess of 140 people using the service, with more frequent reviews held as needed. The registered manager and senior staff acknowledged that the current management and staffing are not sufficient to carry out the annual reviews. There is evidence that efforts are made so that guests are involved in some decision making about the home, such as day to day living and social activities. However areas where guests can affect change in the service may be limited. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Links with the community are generally good and there are some planned and spontaneous activities available. Guests are usually able to take advantage of and develop socially stimulating opportunities. The meals are generally good with evidence that guests are offered choice and quality meals. There is currently not sufficient evidence relating to how the special dietary and nutritional needs of some guests are being met. EVIDENCE: There is good information recorded on guests personal profiles about preferences relating to their leisure time activities. From discussions it is evident that staff try to devise activities and outings to suit the guests accommodated at any particular time. Currently there are not always sufficient numbers of day care staff to provide adequate support and supervision for the numbers of guests with diverse needs choosing to remain at Kathleen House Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 14 during the day. It is indicated in case files that two brothers like to attend church, however the home has not arranged this to date. The explanation is that they can only go if there are sufficient staff available. Guests spoken to during this visit have indicated that they would like to go to the local pub, cinema, shopping - particularly to the Merry Hill Centre. They also like watching TV, listening to DVDs, playing games and doing crafts with staff and other guests. People have been making Christmas cards during this visit, which they are proud to show off. There are activity sheets, and communication sheets, seen on case files for messages between Kathleen House and the main carers, families and other venues such as day care opportunities. Discussions with parent of one of the guests who uses the service regularly, during the visit, states that she is very happy with the home, seem to have staff here for some time who know her well and are aware of her needs and the risk of seizures. This parent is not aware of what her daughter has to eat, whilst at Kathleen House, but states she seems happy enough. During the visit staff have been warm and friendly as well as being respectful towards guests. Members of staff can be heard using each guests preferred name. These are recorded in the sample of personal profiles assessed. Staff know and understand when guests’ need to be alone on occasions and their right to choose to be involved, such as the two who have taken an active role in this inspection. A senior member of staff does the shopping on a weekly basis, with menus devised to meet the preferences and needs of guests accommodated. These are generally recorded retrospectively. At home does not have menus in any alternative formats. During a tour of the premises it is noted that there although there is a variety of frozen, canned and dried foods, there are only limited supplies of fresh fruit, salad and vegetables. The home currently only provides UHT long life skimmed milk, which may not be to the liking of all guests and may not provide sufficient nutrition for guests who may be nutritionally at risk. There is insufficient documentary evidence that all guests food / drink preferences are recorded as part of their personal profile and that menus demonstrate that meals provided offer guests accommodated a nutritious choice of meals according to their preferences. There is no evidence that a guest with a hiatus hernia, high blood pressure and high cholesterol is being provided with a low-fat, low-salt, low sugar diet on a little and often basis in accordance with guidance recorded in his personal profile. There is also insufficient written evidence of this persons daytime activities in his daily notes. It is positive that his personal file contains information from the Internet about hiatus hernias. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal support in this home is offered in such a way as to promote and protect guests’ privacy, dignity and independence. The health needs of guests are generally well met with good evidence of multi disciplinary working taking place on a regular basis. The systems for the administration of medication are generally good with clear and comprehensive arrangements being in place to ensure guests medication needs are met. EVIDENCE: There is evidence that Kathleen House uses the assessment process and personal profile to record guidance for staff for the preferred methods of assistance with all aspects of personal care / transfers etc., for all guests as part of their continuum of care. Discussions and observations indicate that personal and intimate care is given in accordance with guest’s wishes. The staff group is predominantly female, though the manager has recruited male carers recently. There is good written evidence of personal care as part of each Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 16 guests daily notes. Times of rising and retiring are flexible, the only limitations relate to guests wishing to continue to attend day care, where they have to be ready for set transport times. All guest bring their own clothes and preferred personal possessions into the Home for the duration of their visit, and items are documented on inventories. The home ensures that specialist health requirements are clearly recorded in each guest’s personal profile to provide a continuation for their health needs usually met in the community. There is good evidence recorded on communication sheets between health care professionals, district nurses, GPs and community dietician. However the home must expand and improve the information for a guest visiting Kathleen House for a longer stay, whilst alternative permanent accommodation is found. This person has complex needs including nutrition via a peg feed. There is an absence of evidence of a written protocol and staff training from the district nurse for staff to undertake this procedure. In addition it is indicated in a letter from Dr Treizise that this persons weight had not been recorded since early October 2006, though he has subsequently been weighed in December 2006 and his weight is stable. There is written evidence that his medication has been reviewed and revised for improved control of his seizures. The home has the organisational policy medication policy, however this needs to be updated and expanded to ensure staff are supported by procedures and practice guidance specific to Kathleen House, which offers a specialist respite service. There is evidence that staff are generally aware of good practice, though the home does not have documentary evidence that the organisations medication training is accredited. The home has increasing amounts of medication and the storage facilities are not all suitable, for example a lockable wooden cabinet has been installed, which does not have sufficient space and does not comply with Royal Pharmaceutical Society of Great Britain Guidance, especially regarding infection control. Generally good attention is given to maintaining and updating medication records and systems are in place to make sure that medication records are fully completed. However the MAR sheets contain some handwritten entries, which have not be signed and witnessed by appropriate staff. In addition not all medication received for each visit is fully and accurately recorded. Some guests have medication to be given on an as and when needed basis and currently the home does not have written guidance in guests profiles for the use and evaluation of PRN medication. There is evidence that guests who have the capacity are encouraged to keep and take their own medication. There is one guest self-medicating during this inspection visit and the home has a documented risk assessment in place. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has a complaints system, produced in pictorial formats, with evidence that guests feel that their views are listened to and acted upon. Policies, procedures, guidance have been implemented in order to provide guests with more safeguards from abuse. There is not sufficient evidence to demonstrate all staff have received training relating to the protection of vulnerable adults and have a good awareness of their responsibilities. EVIDENCE: The home has a comprehensive complaints policy and procedure, with helpful flow charts in an innovative pictorial format. These help guests to understand the process. Guests with verbal communication skills state that they can tell the manager or staff about any things they do not like. The Home has received 10 complaints since the inspection visit in November 2005, which have been appropriately investigated and resolved. Nine complaints were upheld. The Home’s complaint log is satisfactory clearly identifying outcomes of investigations and actions. The home should consider ways to involve the residents without verbal communication skills. The home has comprehensive policies and procedures, however there still some gaps in staff training relating to the areas of the protection of vulnerable adults, understanding abuse, whistle-blowing, bullying, dealing with aggression from guests towards staff, use of physical intervention / restraint, and management of stress. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 18 The home has a finalised copy of the multi-agency policy and procedure for the protection of vulnerable adults Safeguard and Protect available for staff guidance. The registered manager has made sure that all staff have read and signed the document to demonstrate their awareness. During the examination of records there is a reference, reported 9/12/06, assessment relating to the challenging behaviour exhibited by the guest who slapped another guest. There is no evidence of a documented risk for this persons challenging behaviour and the incident has not been investigated or referred to the Dudley Social Services Adult Protection Manager. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is generally good providing guests with an attractive and homely place for short respite stays. EVIDENCE: Kathleen House comprises three separate bungalows set in well-maintained gardens, with ample off-road car parking in the grounds. The bungalows are purpose-built to provide a comfortable, home like and safe environment for younger adults to have enjoyable respite stays. One of the visiting guests enjoyed showing the inspector around one of the bungalows, including the bedroom he is occupying for this visit. The exteriors and interiors continue to be maintained to generally acceptable standards, with bright decor and interesting, attractive fixtures and fittings. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 20 During the tour of the premises a sample of guest bedrooms have been viewed. The bedrooms in each bungalow are colour co-ordinated, with red, blue, yellow and green themes. The guest acting as an escort explained that people could bring their personal possessions with them for their visit. There is evidence that some guests chose to bring in more personal items than others. An inventory of personal possessions is completed for each guest for each visit. Each bungalow has an assisted communal bathroom and communal toilets in addition to the bathing and toilet facilities in each en-suite bedroom. The bathrooms are clean, tidy and attractively decorated with stencils or seascapes. Each bungalow has a well organised, which guests can use to make drinks and snacks, either alone or with staff assistance according to their risk assessment. Parts of each bungalow now need improvement; the home has been redecorated since November 2004. Previously the home has been completely redecorated throughout every 18 - 24 months. The maintenance person is also responsible for the maintenance at a number of other homes. The areas identified as requiring attention at this inspection visit are: Internal redecoration of all 3 bungalows, especially 59a, which has not been repainted since November 2004 Minor repairs to kitchens at 59 and 61 Addison Road Recalibrate or replace the defective food probes Rectify the worn strip of carpet between the lounge and hall at 61 Addison Road Rectify the staining around the washbasin in yellow bedroom Replace the defective light in 59a green bedroom en suite To provide suitable dining table and chairs fit for the guests using them, in sufficient numbers to accommodate staff sitting with guests at meal times The registered manager must undertake a documented audit of the premises, from which a prioritised programme of maintenance and redecoration must be devised. The garden and grounds to the home are tidy and look very well maintained, especially at this wintertime of year; this is mainly due to the continued time and attention given by a volunteer. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is a generally stable staff team. Staff morale is good resulting in an enthusiastic workforce that works positively with guests to improve their whole quality of life. The home follows rigorous recruitment process, which safeguard vulnerable people. EVIDENCE: During discussion it is evident that staff at the home are generally well informed and well motivated and there is a good team spirit. The registered manager ensures that all members of staff have an induction and structured probationary period, which is used to make sure that they are aware of their role and responsibilities. On occasions the registered manager has extended the probationary period, where necessary. Although the staff rotas appear to show that the home is maintaining usual staffing levels to meet the varying needs and varying numbers of guests accommodated during each week, some outcomes indicate that staffing levels need to be reviewed and where necessary increased. Examples are to enable Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 22 and support guests cultural and spiritual needs and those who are at home during the daytime. There must also be sufficient senior care hours to update, review and maintain each guests personal profile, risk assessments and formal annual reviews. Information shows that one person has resigned since the last inspection and two new staff have been recruited. A sample of staff personnel records examined is generally satisfactory. All staff personnel files contain a recent photograph, completed application form, satisfactory references and a copy of the interview questions and answers. A member employed on a POVA first basis, had a written risk assessment in place, however it did not have a named supervisor identified. The registered manager ensures that staff signatures are obtained to demonstrate the receipt of their individual copy of the General Social Care Council (GSCC) Code of Conduct. There is a staff team of 30 people, excluding the registered manager. There is a training and development plan in place, however there are significant gaps in professional training and mandatory training achieved. To date only 6 staff have achieved an NVQ 2 or LDAF award, which is 20 , a shortfall of 30 of the National Minimum Standard of a minimum ratio of 50 of care staff with the qualifications. It is stated that 8 staff have been registered as candidates for the LDAF award. The organisation must support the registered manager with a strategy to achieve the required level of staff training. Formal and structured supervision sessions are now in place for each member of staff and the registered manager uses a calendar to remind senior staff when staff supervision sessions become overdue. Remedial action is being taken to help people to catch up to achieve the target of six documented sessions every 12 months. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42, 43 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The registered manager of the home continues to provide generally clear leadership and communication systems are generally effective, though there insufficient evidence of support and monitoring from the registered provider in accordance with the legal role and responsibilities. There are systems in place to consult guests about the service provided. The compliance with all aspects of records and health and safety is currently not satisfactory, which poses potential of risks residents safety and well being. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 24 EVIDENCE: Mrs Dawn Welding has been successful with her application to the CSCI to be the Registered Manager at Kathleen House. She has many years of experience working at the Home and has registered, as a candidate to achieve the Registered Managers Award (RMA) through the Organisation’s accredited training centre, awarding body is City & Guilds. The award includes the A1 NVQ Assessors Award and she has a target to complete the training by the end of 2007. She is committed to her own personal development and has recently completed Train the Trainer award in November 2006. The registered manager provides some in house training for the staff at Kathleen House and at other homes. The guests, relatives and staff feel that the registered manager is approachable and supportive. It is evident that the registered manager is committed to providing a quality service for the people using the home, however her resources are stretched and compromised. The organisation must seriously consider additional formal support for the registered manager with administration and management tasks. The home continues to receive some support from Ms Hilary Jordan, the previous registered manager and currently group manager. She has increasingly taken wider responsibilities for new initiatives and line management for other homes within the organisation. Records at Kathleen House have previously been very good. However omissions have been identified at this visit and there are risks of failures to maintain standards. In addition CSCI has not received evidence of consistent Regulation 26 visits and the organisations internal quality assurance system has failed to provide an internal audit and report for Kathleen House within the organisations own timescales. Furthermore actions have not taken place to implement the improvements required at the previous quality audit in February 2006. The registered manager has not had sufficient allocated time to maintain the homes quality assurance system. There is currently no up to date annual development plan and there are currently no collated guests, relatives and stakeholder survey results. The manager continues with some internal quality audits and the home continues to have bungalow of the month to encourage and motivate staff. Regular staff meetings take place but there are no regular meetings for guests and relatives. The manager is continuing efforts to ensure that documented risk assessments and risk management strategies relating to the environment are reviewed, expanded and implemented. However the homes health & safety policy needs updating and fire risk assessment is also currently due to be updated. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 25 A sample of fire safety and maintenance service records examined are generally satisfactory, though remedial action identified, as part of the hoists LOLER service is outstanding. There are a total of 21 recorded accidents involving guests and 14 accidents involving staff since November 2005 currently consistent documented accident analysis are not taking place. There continue to be outstanding requirements relating to the evidence to demonstrate the home is conducted on a viable financial footing. The Registered Proprietor has not to date made a copy of the last years audited accounts for Kathleen House and a business and financial plan to the CSCI for consideration. Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 2 2 2 2 Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4, 5 Requirement To update the statement of purpose and service user guide including the changes of information relating to the registered manager, management arrangements, increased service and staffing and correct contact details for the CSCI, in user friendly formats To ensure that each guest is issued with an up to date contract including details of fees, with a signed and dated copy held on their case file 1) To develop care plans otherwise known as personal profiles to be person centred and in alternative formats according to each persons capabilities and ensure all aspects of care and social needs are included 2) To ensure that all personal profiles are reviewed and updated at least annually or as needs change at the next respite visit Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 28 Timescale for action 01/06/07 2 YA5 5(1) 01/06/07 3 YA6 15(1) 01/06/07 4 YA17 13(1) To implement monitoring arrangements to ensure all guests dietary needs are appropriately catered for (Timescale of 01/12/05 Not Met) 1) To provide clear documentary evidence that all guests food / drink preferences are recorded as part of their personal profile and that menus demonstrate that meals provided offer guests accommodated a nutritious choice of meals according to their preferences 2) To ensure that there are sufficient supplies of fresh fruit and vegetables at all times 3) To explore guests preferences for milk and provide, choices in addition to the UHT long life skimmed milk, especially for guests who may be nutritionally at risk 5) To implement individual records of food / fluid intake for guests with special dietary needs 6) To develop menus in alternative formats, such as pictorial, to be used to provide guests with realistic and meaningful choices at each meal time 01/06/07 5 YA17 13(1) 17(2) 01/04/07 6 YA19 13(1) 1) To maintain weight records for any guest staying for longer respite periods, and especially guests who are nutritionally at risk 2) To provide documentary evidence of staff training for all 01/04/07 Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 29 staff involved with peg feeds 3) To ensure that there is a written protocol for peg feeding approved by the District Nurse, readily available for staff guidance 7 YA20 13(2) 1) To provide adequate storage for medication in accordance with the Medicines Act 1968, Misuse of Drugs Act 1971, guidance from the Royal Pharmaceutical Society of Great Britain and infection control guidelines 2) To provide all staff involved in the administration of medication with accredited medication training 3) To review and update the homes medication policy and procedures 4) To ensure all medication brought into the home is clearly receipted, dated and signed for by 2 staff 5) To ensure that there is written guidance in guests profiles for the use of PRN medication 8 YA23 13(6) 1) To undertake a documented risk assessment relating to the challenging behaviour exhibited by the guest who slapped another guest (reported 9/12/06) and ensure that the incident is referred to the Dudley Social Services Adult Protection Manager 01/01/07 01/06/07 Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 30 2) To ensure that all incidents of physical aggression between guests are appropriately recorded and referred in accordance with Safeguard & Protect procedures 9 YA24 23(2) 1) To undertake a documented 01/06/07 audit of the premises, from which a prioritised programme of maintenance and redecoration must be devised and implemented, to include: - Internal redecoration of all 3 bungalows, especially 59a, which has not been repainted since November 2004 - Minor repairs to kitchens at 59 and 61 Addison Road - Recalibrate or replace the defective food probes - Rectify the worn strip of carpet between the lounge and hall at 61 Addison Road - Rectify the staining around the washbasin in yellow bedroom - Replace the defective light in 59a green bedroom en suite 2) To provide suitable dining table and chairs fit for the guests using them, in sufficient numbers to accommodate staff sitting with guests at meal times 10 YA32 18(1)(c) To devise and implement a strategy to achieve at least a 50 ratio of care staff qualified to NVQ2 / LDAF within an agreed timescale of no longer than 12 months 01/12/07 Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 31 11 YA33 18(1)(a) 12(1) 1) To ensure that there sufficient numbers of staff available so that guests have opportunities to follow their faith, such as attending church or cultural functions 2) To ensure that there are sufficient numbers of staff available to provide day care activities, within the home and externally to the home, for those guests not participating in activities with outside agencies 01/06/07 12 YA34 17(2) Sch2 and 4 A copy of a signed contract / terms & conditions of employment - for all staff including bank staff (Timescale of 31/08/05 and 01/01/06 Not Fully Met) To ensure risk assessments and staffing rotas include the named supervisors for any member of staff employed on a POVA first basis To ensure that all staff have received up to date mandatory training: - Moving & Handling - First Aid - Food Hygiene - Infection Control - Health & safety and in addition - Person Centred Care Planning - Abuse awareness / protection of vulnerable adults - Dealing with challenging behaviour The registered person must give serious consideration to additional support for the registered manager to enable her to fulfil her legal DS0000024949.V322203.R01.S.doc 01/06/07 13 YA34 17(2) Sch2 and 4 19(11) 18(1)(c) 01/04/07 14 YA35 01/06/07 15 YA37 24 01/04/07 Kathleen House Version 5.2 Page 32 responsibilities, especially as the number of guests using the service have increased by more than 33 , increasing her administrative, supervisory and training workloads 16 YA39 24 1) To produce an up to date annual development plan for the home as part of an effective quality assurance system 2) To ensure that the 6 monthly audits by other managers from within the organisation take place and that actions identified in quality audits are completed 3) To forward copies the following to the CSCI office, Halesowen - The collated results of the homes service user surveys - The collated results of the homes relatives surveys - The collated results of the homes stakeholder surveys 17 YA39 26 The registered person must ensure that unannounced visits and reports regarding the conduct of the home are resumed on a consistent monthly basis, with reports made available to the registered manager and the CSCI 01/04/07 01/06/07 18 YA40 17(1) The registered manager must 01/06/07 review and revise, as needed, all policies, procedures and good practice guidance on a regular basis, at least annually, signing and dating them. This especially applies to the Health & Safety policy and medication policy. DS0000024949.V322203.R01.S.doc Version 5.2 Page 33 Kathleen House 19 YA42 13(4) 1) To restock the first aid boxes at 59a and 61 Addison Road 2) To resume the documented accident analysis on a regular basis (Timescale of 01/12/05 Not Met) 01/04/07 20 YA42 13(4) 1) To update the homes fire risk 01/06/07 assessment 2) To resume regular monthly tests of all hot water outlets accessible to guests, ensuring they are maintained between 38 C and 43 C (41 C for showers) at all times 3) To provide mast bumper and handle cover for hoist as identified in LOLER service 28 November 2006 4) To undertake documented weekly visual checks of slings 5) 4) To undertake documented weekly visual checks of bedrails 21 YA42 13(4) To ensure that all incidents of violence & aggression and accidents to staff by guests are appropriately reported and analysed with revised risk assessments when necessary To develop a business and financial plan, forwarding copies to the CSCI Satellite Office Halesowen for consideration (Timescale of 31/10/04 and 31/08/05 and 01/01/6 Not Met) 01/04/07 22 YA43 25 01/06/07 Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 34 23 YA43 25 To send a copy of the last years 01/06/07 audited accounts for Kathleen House to the CSCI Satellite Office - Halesowen. (Timescale of 31/10/04 and 31/08/05 and 01/01/06 Not Met) 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 That written documents such as the Statement of Purpose, Service User Guide, menus, newsletters and relevant procedures e.g. fire, are developed in alternative formats, for example, pictorial That advice is sought from the community dietician regarding the homes menus and food stocks That as and when washing machines are replaced, new equipment is compliant with requirements of standard 30 That consideration is given to actively involving the guests using the service and seeking their views on a regular basis, through meetings or a council or other means That serious consideration is given to providing the home with internet and email facilities for access to up to date guidance and communication with the CSCI, and as a means of communication for the guests using the service 2 3 4 YA17 YA30 YA39 5 YA39 Kathleen House DS0000024949.V322203.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 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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