Inspection on 07/11/07 for Kathleen House

This inspection was carried out on 7th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 3 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 19/12/06

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 Lesley Webb Key Unannounced Inspection 7th November 2007 09:50 Kathleen House DS0000024949.V349497.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.V349497.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.V349497.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.V349497.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. December 2006. 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.V349497.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that was undertaken by one inspector on a Wednesday between 9.50am and 8.00pm. During the visit time was spent talking to staff and residents, examining records and observing care practices before giving feedback to the registered manager. The care packages of three individuals were case tracked in order to help form judgements on the quality of service provided by the home. Five guests surveys were completed and returned to the Commission for Social Care Inspection (CSCI) and information was also supplied by the home prior to the inspection, the contents of which was also used when forming judgements on standards of service provided. The inspector was shown full assistance during the visit and would like to thank everyone for making her welcome. What the service does well: Staff have a good understanding of the communication needs of guests. As one person explained, “some people are not verbal but we look at facial expressions, some give one-word answers. We look at noises that they are making, movements, moods, facial expressions”. Guests appear happy with activities provided. For example one guest explained, “staff put music on that I like and we make cakes, I love coming here”. All staff that were interviewed demonstrated understanding of monitoring the changing health needs of guests. For example one person explained, “we are always watching for signs, if bit chesty, too hot or cold, usually you see what like when they come in so know if something not right. I would ask senior and other staff to check and keep eye on, put in notes”. Three of the five service user surveys completed and returned to the CSCI state that individuals know who to speak to and how to make a complaint, there is a comprehensive complaints policy and procedure, which has been reviewed and all staff that were interviewed demonstrated understanding of supporting guests who might wish to complain. 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. The exteriors and interiors Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 6 continue to be maintained to good standards, with bright decor and interesting, attractive fixtures and fittings. As at previous inspections staff demonstrated a commitment to their job roles and a good understanding of the needs of the service user group they support. Recruitment processes are good and offer safeguards to guests. The guests, relatives and staff feel that the registered manager is approachable and supportive. As one member of staff explained, “the manager is good, can’t fault really, any issues are resolved” and another “she is very approachable”. What has improved since the last inspection? The statement of purpose and service user guide have been updated and both are now availible in colourful pictoral formats that aid communication. For those guests who remain at the home during the day a programme has been implemented to ensure a variety of activities are offered. All of the requirements relating to meals identified at the previous inspection have now been met ensuring the home can be confident the dietary needs of guests are catered for. For example a range of milks and fresh fruit are now provided, menus are in the process of being updated and have been developed in a pictorial format and records relating to food and fluid intakes for guests with special dietary needs have greatly improved. Previous requirements relating to providing evidence of staff receiving training with ‘peg’ feeds and producing a written protocol for this are now met. Medication systems have improved offer greater protection to guests. For example all medication cabinets now comply with relevant legislation, the majority of staff have now completed accredited medication training and medication is now clearly receipted, dated and signed for when brought into the home. Internal redecoration of the bungalows has been completed, minor repairs undertaken and some washing machines replaced. The registered manager confirmed that dining chairs are going to be replaced by the Registered Provider and long with some curtains. All of these improvements ensure the home is maintained to a good standard. Kathleen House DS0000024949.V349497.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.V349497.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.V349497.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 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people to use this service have the information needed to decide on its suitability. EVIDENCE: Information supplied by the home prior to the inspection states as what we do well ‘up to date statement of terms and conditions for all service users are now in place, statement of purpose and service user guide inprocess of being developed in pictorial and all service users are assessed as and when needs change or parents/carers inform us of any change’. Evidence gained through talking to the registered manager and looking at records indicates that in the main this information is correct. For example the statement of purpose and service user guide were examined and found to have been updated and both are now availible in colourfull pictoral formats that aid communication (meeting previous requirements). We sampled the files of three people who are currently accessing the respite service and found one to contain an up to date statement of terms and conditions of residency, with the registered manager explaining that she is in the process of arranging meetings with individuals and their representatives in order that the new conditions can be discussed and agreed. Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 10 Since the last inspection there has been an adult protection investigation that resulted in the service reviewing its admission processes to include greater numbers of visits to to service in order that it can be confident it obtains all the required information to meet individuals needs. The registered manager confirmed that as yet no written policy or procedure reflecting these changes has been implimented. It is recommended action be taken to impliment an assessment procedure that includes the increased requirements relating to visits to the service in order that everyone is aware of their roles and responisiblities and to ensure prospective residents can be confident their needs are fully assessed. Kathleen House DS0000024949.V349497.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 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some efforts are made to involve individuals in decisions about their lives. Further efforts to introduce person centred plans will offer further opportunities for individuals to play an active role in planning the care and support they receive. 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. Although fairly basic in content (for example not including short and long term goals and aims) these appear appropriate to the service provided. The personal profiles generally contain a summary including preferred name, personal care, preferred daily routines, times of rising and retiring and sleeping patterns. 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. Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 12 Requirements were made at the previous inspection to develop personal profiles to be person centred and to ensure that reviews are undertaken at least annually or as needs change at the next respite visit. The registered manager confirmed that action has been taken to address these issues with ten profiles now in a person centred format and appointments made with individuals to gather information in order to review and change others. The respite service has over one hundred individuals who receive a service from the home. This was discussed with the registered manager, with the inspection suggesting that those who regularly receive a service being prioritised with regards to having profiles reviewed and updated to ensure the home can be confident of meeting the needs of its regular guests. There is 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 and some were found to be generic and not based on the individuals needs and capabilities. 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. The registered manager confirmed that service user surveys are completed annually in order to obtain their views and that on one occasion guests had sat in a staff meeting. It was suggested that meetings be arranged twice a year specifically for guests and their representatives in order that processes support individuals further in decision-making. Staff demonstrated a good understanding of the communication needs of guests, as one person explained, “some people are not verbal but look at facial expressions, some give oneword answers. We look at noises that they are making, movements, moods, facial expressions”. Kathleen House DS0000024949.V349497.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): 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service area able to make choices about their life style. Generally social, educational, cultural and recreational activities meet individuals’ expectations. EVIDENCE: Information supplied by the home prior to the inspection states as what they do well ‘in house activities that include music, massage, beauty, arts & crafts, games, cooking’ and that they have improved in the last 12 months by ‘developing a day care programme’. Evidence gained by observing care practices, talking to people and examining records indicates that this information is correct. For example one guest explained, “staff put music on that I like and we make cakes, I love coming here”. The majority of people who use the respite service continue to access their regular day care services whilst staying at the home. Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 14 For those who remain at the home during the day a programme has been implemented to ensure a variety of activities are offered. Five service user surveys were completed and returned to the Commission for Social Care Inspection (CSCI) prior to the visit. Of these three state they do what they want and two that they cannot. Additional comments were made including ‘I only go in Kathleen house for a short time so there is not a problem, it may be a problem if I needed to stay longer’ and ‘I can do what I want within limits but staff have to keep me away from the kitchen for my own safety’. As at the previous inspection staff were observed to be warm and friendly as well as being respectful towards guests. Members of staff were heard using each guests preferred name. All of the requirements relating to meals identified at the previous inspection have now been met ensuring the home can be confident the dietary needs of guests are catered for. For example a range of milks are now provided, menus are in the process of being updated, fresh fruit is available, the menu has been developed in a pictorial format and records relating to food and fluid intakes for guests with special dietary needs have greatly improved. The registered manager confirmed that advice has been sought from the community dietician regarding the homes menus. The home does not employ separate kitchen staff, with care workers undertaking cooking responsibilities. It is recommended that staff received training in nutrition and diet to enhance further the improvements already made in this area and to ensure they can be confident they have the appropriate knowledge to support guests with specific dietary needs. Kathleen House DS0000024949.V349497.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Guests receive personal support in the way they prefer and require. For example preferences about how they are moved and supported are recorded and individuals were seen being given personal support in the privacy of their bedrooms. As already mentioned times for rising and retiring, meals and other activities are flexible according to individuals needs and preferences. As at the previous inspection there is good written evidence of personal care as part of each guests daily notes. Individuals are fully supported to access health care facilities during their respite stay and on occasions this has included emergency treatment at hospital. Previous requirements relating to providing evidence of staff receiving training with peg feeds and producing a written protocol for this are now met. As a result of a previous adult protection investigation the service has been looking at ways of improving its health records. Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 16 Detailed daily records are maintained by staff that are now complimented with fluid intake charts. The registered manager confirmed that staff have not received any specific health care training. As mentioned earlier in this report it is recommended that nutrition and health training be provided to ensure staff have the appropriate knowledge to support individuals. All staff that were interviewed demonstrated understanding of monitoring the changing health needs of guests. For example one person explained, “we are always watching for signs, if bit chesty, too hot or cold, usually you see what like when they come in so know if something not right. I would ask senior and other staff to check and keep eye on, put in notes”. As Kathleen House offers a respite service a monitored dosage system for the management of medication cannot be used. The records and medication of three guests were examined and found in the main to be correct apart from an ‘over the counter medication’ not being appropriately recorded when entering the home, one medication being dispensed differently to instructions on the pharmacy dispensing label and one medication not recorded on the medication administration sheets. A number of requirements and recommendations have been made at previous inspections with regards to medication, the majority of which are now met, which is a credit to the service. For example all medication cabinets now comply with relevant legislation, the majority of staff have now completed accredited medication training and medication is now clearly receipted, dated and signed for when brought into the home. The homes medication policies and procedures have been reviewed but these are not specific to the service provided by Kathleen House. It is strongly recommended these be amended to ensure staff have accurate information to refer to and to offer greater protection to guests. It is also recommended that the temperature in the medication cabinet be monitored to ensure medication is stored as per manufactures guidelines. Kathleen House DS0000024949.V349497.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 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service are supported to express their concerns and have access to a robust, effective complaints procedure. Safeguarding procedures have not always been followed, having the potential to place people at risk. EVIDENCE: Information supplied by the home prior to the inspection states as what they do well ‘all complaints received are dealt with as per organisational policy, good relationships are fostered between service users and staff to make it easier to complain to staff on a 1-1 basis if they so wish, a record of the complaint, action taken and responses given are kept an reviewed as required, we have a complaints policy covering complaints made by members of the public and staff and family members have built mostly positive relationships where family member are comfortable to approach staff with any concerns or complaints they have’. Evidence gathered during the inspection suggests that in the main this information is correct. For example there is a complaints log, which details the investigation and outcome of complaints, three of the five service user surveys completed and returned to the CSCI state that individuals know who to speak to and how to make a complaint, there is a comprehensive complaints policy and procedure, which has been reviewed and all staff that were interviewed demonstrated understanding of supporting guests who might wish to complain. It was noted that the records maintained of complaints do not include notifying the complainant in writing (as per the written procedure). Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 18 It is recommended this be addressed to ensure the home complies with its own procedure and to ensure complainants are fully informed. The home has comprehensive policies and procedures relating to adult protection and a copy of the multi-agency policy and procedure for the protection of vulnerable adults Safeguard and Protect available for staff guidance. A requirement made at the previous inspection to complete a risk assessment relating to challenging behaviour and ensuring that the incident was referred to the Dudley Social Services Adult Protection Manager is now met. The registered manager confirmed that she informed the adult protection team verbally but did not make a written referral due to the time lapse from the incident to referral. There has been one adult protection investigation since the last inspection with the outcome being no wilful actions of neglect by the home. Some deficits in recordings were identified, with action taken by the home to rectify these (as detailed earlier in this report). When examining accident records we found three recorded incidents of aggression between guests. The registered manager confirmed that no safeguarding referrals had been made for any of these. Due to the potential risk to individuals an Immediate Requirement Form was issued during the inspection instructing that all incidents of physical aggression between guests must be referred in accordance with local authority safeguarding procedures and that this must take effect immediately. The registered manager agreed to ensure this occurs. There are currently twenty-seven staff that work at the home, nine of who have received abuse training. In addition to this abuse is also discussed in other training that some staff have undertaken such as the NVQ. It is recommended that greater numbers of staff receive abuse training that includes discussion of the local authority safeguarding procedures to ensure knowledge and practices reflect local authority guidelines. All three staff that were interviewed demonstrated understanding of adult protection and their responsibilities within this area. As one person explained, “abuse comes in many forms, we must take care with assisting with eating, using right cutlery, food not too hot, make sure people are changed regular, turned regular in the night, make sure personal hygiene carried out, dressing, all comes into it. I would report anything if suspicious”. Kathleen House DS0000024949.V349497.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. 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. A tour of the premises was undertaken with one of the visiting guests enjoying showing the inspector around one of the bungalows, including the bedroom she is occupying for this visit. The exteriors and interiors continue to be maintained to good standards, with bright decor and interesting, attractive fixtures and fittings. Each bungalow has an assisted communal bathroom and communal toilets in addition to the bathing and toilet facilities in each en-suite bedroom. Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 20 The bathrooms are clean, tidy and attractively decorated with stencils or seascapes. Since the last inspection the majority of requirements previously identified have been met, with evidence that those remaining have actions in place to rectify. For example internal redecoration of the bungalows has been completed, minor repairs undertaken and some washing machines replaced. The registered manager confirmed that dining chairs are going to be replaced by the Registered Provider and long with some curtains. It was noted that some of the secondary glazing in bungalow 59 appears faulty, it is recommended action be taken to repair this in order that the building continues to be maintained to a good standard. Infection control appears good at this home with all parts of the home seen to be hygienic, clean and tidy. People who completed surveys and returned them the CSCI prior to the visit reiterated this. All state that ‘the home is always fresh and clean. There is a separate laundry in each of the three bungalows, all of which appear appropriately furnished. It was noted that the heat in two of the laundries felt quiet excessive and that some personal protective equipment was not available for use. Action should be taken in both of these areas to ensure good infection control standards are maintained. Kathleen House DS0000024949.V349497.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): 31,32,33,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are committed to their roles and deployed in sufficient numbers to support the people who use the service. EVIDENCE: As at previous inspections staff demonstrated a commitment to their job roles and a good understanding of the needs of the service user group they support. Three members of staff were interviewed, all of whom gave good exampled of how they ensure the needs of guests are met. For example one person explained, “We always check the care notes when they come in to make sure nothing changed e.g. diet what eating, personal care needs”. 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. Discussions with the registered manager and examination of rotas demonstrate that seven staff are on duty in the morning until 10am (two in each bungalow and a senior who floats between). After 10am Monday to Friday this reduces to one member of staff due to guests attending daycentres Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 22 (however if three or more guests remain at home additional staff are brought in). Then after 4pm this increases back to seven staff. During the night four staff are on duty, one in each bungalow and a float. At weekends seven staff are on duty during the day and early evening. In addition to this the manager undertakes the majority of her hours supernumery to care. The registered manager confirmed that additional staff is also arranged when required in order that appointments and activities can be undertaken (meeting a previous requirement). The recruitment records of three members of staff were examined to assess if practices safeguard guests. All files contained a completed application form, satisfactory references, enhanced CRB disclosures and a copy of the interview questions and answers. 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. It is recommended that a photograph of each person and two forms of identification be obtained to add further safeguards to guests. A training matrix and individual staff training records were examined. Of the twenty-seven staff working at the home twenty-two have undertaken equal opportunities training, fifteen epilepsy and twelve peg feed training. Thirteen staff are Learning Disability Award Framework accredited, with a further five registered to undertake this award and seven staff either hold or are registered to undertake the National Vocational Qualification level 2 (NVQ). As yet no staff have undertaken person centred care training. It is recommended that arrangements be made for sufficient numbers of staff to undertake this training to ensure knowledge and practices reflect current good practice guidelines and that action be taken by the home to ensure greater numbers of staff achieve a NVQ. Kathleen House DS0000024949.V349497.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): 37,38,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect. Further work with regards to quality assurance and health and safety monitoring is needed to ensure the health and welfare of people is fully met. EVIDENCE: The registered manager of the home continues to provide generally clear leadership and communication. The guests, relatives and staff feel that the registered manager is approachable and supportive. As one member of staff explained, “the manager is good, cant fault really, any issues are resolved” and another “she is very approachable”. It is evident that the registered manager is committed to providing a quality service for the people using the home. Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 24 A requirement was made at the previous inspection to give serious consideration of additional support for the registered manger to enable her to fulfil her responsibilities. The registered manager states that she is supported by the organisations development team and that she feels she has sufficient support to do her job, therefore this requirement is now not applicable. There are quality monitoring systems in place that include consulting guests about the service provided. Since the last inspection the registered manager has produced an up to date development plan for the home (meeting a previous requirement) and six monthly audits by other managers from within the organisation are taking place with evidence of action being taken to address areas for improvement (also meeting a previous requirement). Surveys have been completed, with the registered manager in the process of analysing the findings. It was agreed that once completed these will be forwarded to the CSCI. Regulation 26 visits are undertaken, but records indicate these are still not occurring monthly. It is recommended that improvements be made in this area in order that the home meets its legal obligations and to further enhance its quality monitoring systems. A random sample of maintenance and service checks demonstrates areas such as gas appliances; fire equipment and water outlets are being checked. However the records for water temperatures for showers give readings for October 2007 ranging from 30.9 degrees Celsius to 60.1 degrees Celsius (recommended outlets temperatures being 38 C to 41 C for showers). The registered manager provided evidence that action has been taken to address this but was unable to confirm when repairs would be completed. She also confirmed that a risk assessment has not been undertaken regarding the excessive water temperatures. Action must be taken by the home to ensure the risk of injury to guests is being appropriately managed, including the completion of risk assessments that identify how risk of injury can be reduced. Systems for monitoring accidents are in place including the completion of accident records and the analysis of these has been reinstated (as required at the previous inspection). It is recommended that further action be taken to cross reference accident records with other documents such as risk assessments, Regulation 37 notifications, daily records etc as the current system does not allow for effective monitoring (several omissions in recordings were identified specifically to these documents during the inspection). The registered manager agreed that further work should be undertaken in this area. A requirement was made at the previous inspection to update the homes fire risk assessment. We viewed this document and although it states it has been reviewed it appears very basic in content and makes no reference to training, staffing numbers or the varying needs of guests. The registered manager was unable to say when the home was last visited by the fire department neither could she find any reports from them. It is strongly recommended that the home contact the fire department, requesting that they undertake a visit to ensure the health and welfare of guests is maintained. Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 25 Of the twenty seven staff working at the home five hold up to date certificates in moving and handling, six first aid (with two staff booked to undertake this 16th November), eighteen food hygiene (6 booked for 21st November), ten infection control 10, nineteen health and safety (6 booked for 21st November) and eighteen fire. Generally the numbers of staff having undertaken mandatory training is acceptable, however greater numbers of staff must receive moving and handling training to reduce the risk of injury to both guests and themselves. It is also recommended that action be taken to ensure at least one qualified person is on shift in each of the bungalows, with regards to moving and handling, food hygiene, first aid, health and safety, infection control and fire to ensure the health and welfare of guests is maintained. Fire drills take place monthly, with records examined being detailed and informative. Kathleen House DS0000024949.V349497.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 3 2 3 3 X 4 3 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 2 X Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 27 No 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 YA23 Regulation 13(6) Requirement All incidents of physical aggression between guests must be referred in accordance with local authority safeguarding procedures to reduce the risk of harm to individuals. Immediate Requirement Form issued. Action must be taken by the home to ensure the risk of injury to guests due to excessive water temperatures is being appropriately managed, including the completion of risk assessments that identify how risk of injury can be reduced. Greater numbers of staff must receive moving and handling training to reduce the risk of injury to both guests and themselves. Timescale for action 07/11/07 2 YA42 13(4) 07/12/07 3 YA42 13(5) 07/12/07 Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 28 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 YA2 Good Practice Recommendations That action be taken to impliment an assessment procedure that includes the increased requirements relating to visits to the service in order that everyone is aware of their roles and responisiblities and to ensure prospective residents can be confident their needs are fully assessed. That up to date terms and conditions of residency continue to be distributed in order that individuals are fully informed of their legal rights and responsibilities. To continue 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. To ensure that all personal profiles are reviewed and updated at least annually or as needs change at the next respite visit in order that the home can be confident it meets the changing needs of individuals. That those who regularly receive a service be prioritised with regards to having profiles reviewed and updated to ensure the home can be confident of meeting the needs of its regular guests. That meeting is arranged twice a year specifically for guests and their representatives in order that processes support individuals further in decision-making. That risk assessments are completed based on individuals differing needs and capabilities. That risk assessments are regularly reviewed to ensure the home can be confidant needs are appropriately monitored. That staff received training in nutrition and diet to ensure they can be confident they have the appropriate knowledge to support guests with specific dietary needs. All medication entering the home should be recorded and administered as per the pharmacy-dispensing label. Discrepancies should always be clarified with the G.P and DS0000024949.V349497.R01.S.doc Version 5.2 Page 29 2 3 YA5 YA6 4 5 YA7 YA9 6 7 YA17 YA20 Kathleen House outcomes recorded to ensure the homes practices safeguard guests. That the homes medication policies and procedures be amended to reflect practices within the home and to ensure staff have accurate information to refer to and to offer greater protection to guests. That the temperature in the medication cabinets be monitored to ensure medication is stored as per manufactures guidelines. That a photograph is maintained of each guest alongside their medication to reduce the risk of miss-administration. That complainants are notified in writing of outcomes to ensure the home complies with its own procedure and to ensure complainants are fully informed. That greater numbers of staff receive abuse training that includes discussion of the local authority safeguarding procedures to ensure knowledge and practices reflect local authority guidelines. That action is taken to repair the faulty secondary glazing in bungalow 59 in order that the building continues to be maintained to a good standard. That action be taken to reduce the excessive heat and ensure personal protective equipment is available for use in all laundry’s to ensure good infection control standards are maintained. That a photograph of each person and two forms of identification be obtained for all staff to add further safeguards to guests. That arrangements be made for sufficient numbers of staff to undertake person centred care training to ensure knowledge and practices reflect current good practice and that action be taken by the home to ensure greater numbers of staff achieve a NVQ. That improvements be made in the frequencies of Regulation 26 visits being undertaken in order that the home meets its legal obligations and to further enhance its quality monitoring systems. That further action be taken to cross reference accident records with other documents such as risk assessments, Regulation 37 notifications, daily records etc as the current system does not allow for effective monitoring. That the home contacts the fire department, requesting that they undertake a visit to ensure the health and welfare of guests is maintained. Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 30 8 9 YA20 YA23 10 11 YA24 YA30 12 13 YA34 YA35 14 YA39 15 YA42 That action be taken to ensure at least one qualified person is on shift in each of the bungalows, with regards to moving and handling, food hygiene, first aid, health and safety, infection control and fire to ensure the health and welfare of guests is maintained. Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kathleen House DS0000024949.V349497.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!