Inspection on 19/02/08 for Mrs Linda Nicholls

This inspection was carried out on 19th February 2008.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mrs Linda Nicholls 19/02/07

Mrs Linda Nicholls 01/03/06

Mrs Linda Nicholls 20/10/05

Mrs Linda Nicholls 28/02/05

Mrs Linda Nicholls 31/08/04

Mrs Linda Nicholls 11/03/04

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 Mrs Linda Nicholls 573 Chester Road Castle Bromwich Birmingham West Midlands B36 0JU Lead Inspector Karen Thompson Unannounced Inspection 19th February 2008 14:40 Mrs Linda Nicholls DS0000004553.V344502.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 Mrs Linda Nicholls DS0000004553.V344502.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. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mrs Linda Nicholls Address 573 Chester Road Castle Bromwich Birmingham West Midlands B36 0JU 0121 240 7786 0121 240 7786 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) Mrs Linda Nicholls Mrs Linda Nicholls Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th February 2007 Brief Description of the Service: 573 Chester Road is registered as a Care Home for Younger Adults, providing care and support for no more than five people with Learning Disabilities. Mrs Nicholls is the owner of the service and is also registered as the Manager. The home is a detached 5 bedroom family house on a main road on the border of the Castle Bromwich and Smiths Wood areas of Birmingham and Solihull. The residents benefit from single bedroom accommodation and receive care and support within a domestic living environment. Local shops and amenities are a short distance away, and a local day centre is within walking distance. The main shopping area of Chelmsley Wood is a short drive away. Fees vary and are dependent on the needs of residents. Items not covered by the fees include activities, chiropody, clothing, daytrips, hair care, holidays, transport (other than in the case of medical appointments). The current scales of charges for the home are £375 to £834. For up to date fee information the public are advised to contact the home. . Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which was carried out by two inspectors over a one day period. The focus of inspection undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirement, minimum standards of practice and focuses on aspects of service provision that need further development. The inspection commenced at 14:40 hrs and the home/provider did not know that we were coming. The deputy manager was present for the duration of the inspection. Information for the report was gathered from a number of sources: a questionnaire was completed before the inspection by the management team of the home which was sent to us, on the day of the inspection a tour of the building was undertaken, records and documents were examined in relation to the management of the home, conversation with managerial staff and care staff plus some residents. Some residents were unable to communicate their views verbally to the inspector so direct and indirect observation was used to inform the inspection process. Two residents who live in the home were ‘case tracked’ which involves establishing individuals experiences of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experience of people who use the service. Questionnaires were forwarded to a randomly selected number of residents, relatives and health professionals prior to the inspection. Comments from the questionnaires and those residents spoken to have been incorporated into the report. The inspectors would like to thank the residents, relatives, management and staff for their hospitality throughout this inspection. The quality rating for this service is one star. This means that people who use this service experience adequate quality outcomes. What the service does well: Staff are welcoming and friendly. The men all have their own bedrooms and they all contain things that are important for each person. Some of the men were seen to access regularly their rooms during the inspection. Residents are supported to attend a range of daytime activities and or occupations including day centres and colleges. One of the residents of the Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 6 home chooses not to attend a formal day centre and is supported to go out to places of their choosing. Residents are supported to go on holiday each year. Residents are able to access and have support from a range of community healthcare professionals including dietician and speech and language therapists. Residents were seen to be well presented and well dressed. What has improved since the last inspection? What they could do better: The Service User Guide needs to be reviewed so that it is in a format suitable to all residents and each resident should be issued with a guide. Protocols must be in place for specific health care needs so that staff have the information to meet these needs. Care planning has been reviewed by the home but further work is required to ensure that all staff are fully aware of how to support residents. Risk assessments need to involve the residents, the format needs to be more detailed so that it is clear what the risks are and so that they are linked to the care planning process. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 7 A quality assurance system has been introduced to the home, which includes gathering the views and opinions of residents and their representatives. The questionnaires on which this information is gathered needs to be in a format suitable to residents so that information sought and obtained is relevant. Medication management was generally was well managed with the exception of when residents left the building. The home is strongly recommended to contact its dispensing pharmacist to review its current procedures. Residents financial management systems need to be reviewed to ensure they are managed robustly and for the benefit of residents. Independent living skills for residents are not being promoted and these need to be reviewed to ensure residents live a full and empowering life. Menus have been reviewed and the format is accessible to residents, however the homes staff need to ensure that residents are aware of what is available to eat, so choice can be exercised. Record keeping and recording needs to improve to comply with Data Protection legislation that protects residents and staff. Staff’s meeting need to increase in frequency to ensure that any issues if any are resolved quickly The procedure for capturing complaints and concerns must be reviewed, as at present it is not in a format easily accessible to residents. 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. Mrs Linda Nicholls DS0000004553.V344502.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 Mrs Linda Nicholls DS0000004553.V344502.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. Quality in this outcome area is adequate The prospective resident and their relative have information to enable them to make an informed choice about whether or not they not they want to live in the home. The Service Users Guide needs further development so that the information is meaningful to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user guide was produced using some pictures and had been reviewed since the last inspection. It is recommended this be further developed using photographs and pictures so that the information is more meaningful for the people who live there. A copy of the service user guide should be made available to each of the people who live in the home. It was not possible to fully assess the pre-admission process as no new admissions had been made since the last inspection. The admission procedure was looked at and had been updated so that it now includes a three-month settling in period. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6.7.9 Quality in this outcome area is adequate. Residents are not fully supported to develop an independent lifestyle. Care plans are not fully reflecting the needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Progress had been made on developing a care plan format and two peoples care plans were looked at. The individual plans had details of how staff should support residents with their health, communication, personal care and social needs. It contained information about the resident’s likes and dislikes and how to maintain contact with their relatives and friends. It is essential to personal growth and development that opportunities to maintain independent living skills are provided even when residents have limited abilities. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 11 Residents now have a Person Centred Care plan in place, which is in picture format. Care plans need to be cross-referenced to risk assessments so that staff have the additional support and information to meet residents needs. Risk assessments were basic in form and did not indicate resident’s involvement. Person centred plans have been introduced. These are care plans that start with the person, not the service and take into account the individuals wishes about what they want to do and include their requests on lots of things such as leisure, education and housing. The plan has been produced in an easy to read format-using pictures. Residents do have access to advocates, which ensure they have support in expressing their wishes, concerns and rights. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15.16.17 Quality in this outcome area is adequate. Residents are supported to enjoy a range of activities that meet their assessed needs. The mealtime experience needs to incorporate the promotion of independent living skills. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are supported to attend college, day centres and luncheon clubs. A resident has decided not to attend formal day care and is supported by staff to take part in other activities. One resident attends local football matches. Four of the residents attend clubs on three evenings a week where they have the opportunity to take part in leisure activities and socialise with different people. The inspectors were informed that three of the residents recently attended a Valentines disco recently. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 13 It is essential for personal growth and development that opportunities to maintain independent living skills are provided even when residents have limited ability to do so. Two residents are involved in helping cook specific foods but this appears to be the limit of involvement for them and all residents living at the home. The mealtime observation demonstrated that these skills and choice were not being actively promoted. Care plans only briefly refer to personal development and should be developed to include this information. Care plans indicated residents’ spiritual and cultural needs. Three residents attend local church services and are supported to practice their faith. Residents are enabled to maintain contact with relatives. One resident’s relative was observed visiting the home on the day of the inspection. Conversations with staff indicate that they recognise the importance of residents being supported to develop personal relationships. The visiting policy says people are welcome to visit the home. The inspector was informed that four of the residents are going on holiday at Easter and will be staying in a hotel. Menus have been developed into pictorial format for residents since the previous inspection. A staff member cooks Afro Caribbean meals with two residents twice a week. It is a positive that their cultural dietary needs are being addressed. Residents stated that they were not always aware of what was on the menu despite the development of these pictorial menus. The menu repeats each week it is recommended that this be reviewed so that people have a wider choice of meals. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 14 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 adequate. Residents receive the support they need to meet their health care needs. The medication procedure does not fully protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ individual plans seen had details of residents’ personal care routines and preferences. Residents were appropriately dressed in accordance with their age and culture. Residents spoken to said they could go to bed at a time of their choosing, demonstrating there were no restrictions in this area. Health care notes looked at indicate that residents are supported to attend routine G.P, dentist and opticians appointments. There were also no individual protocols in place for management of epilepsy. Staff need to have clear instructions of what to do if an epileptics fit occur. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 15 Staff were monitoring one resident’s blood sugar regularly in relation to their diabetes. All staff need training in diabetic and epileptic care. Protocols for diabetes and epilepsy were reviewed by the home and supplied to the Commision following the inspection. Residents’ records were able to demonstrate regular health input for a variety of professionals, therefore demonstrating a pro-active approach to care. One professional commented that the homes communication with them and other agencies was generally good. The home has no lifting aids but this was not required by any of the current residents. The medication is stored in a locked medication trolley in the kitchen area of the home. The trolley has the facility to be anchored to the wall, but this has not been used it is recommended for increased security that this occurs. The medication trolley was found to be clean and well organized allowing for easy of administration practice. Medication consisted of boxed or blister systems and the medication was auditable. Staff at present dispense medication into a container when residents leave the home for the day centre and the person at the centre giving the medication signs the MAR chart. It is recommended that the home contact their pharmacist and arrange for medication to be dispensed by the pharmacist into a separate bottle or blister pack for specific use whilst out at the day centre. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 16 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 The complaints procedure is confusing and further work is required to ensure concerns are dealt with appropriately. Safeguarding procedures do no follow local guidance so potentially place residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A concern, complaints and grievance procedure is in place. However information within this procedure is very muddled and talks about complaints and grievance and the involvement of people’s social workers. The procedure needs to be made clear so that people living in the home, visitors and the staff team are clear about how concerns are raised and dealt with. Since the last visit CSCI had not received any complaints about the service provided at Chester Road and no complaints had been made to the home directly. An easy to read complaints format is available, which makes it easier for people to understand. Some of the people living there have limited verbal communication skills and are reliant on the vigilance of relatives or staff members who know them well to interpret changes in behaviour or body language, to alert them to the fact that something is amiss. Some people who can communicate verbally may prefer a different way to communicate their complaint. This was discussed with the deputy manager who was keen to Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 17 explore how people could be better supported in raising concerns so that the quality of the service improves and people are empowered. Feedback from professional and relative surveys stated that they were aware of how to make a complaint and that concerns had been addressed appropriately by the home in the past. The safeguarding procedure needs some further development so that staff know how best to support people in the event of an incident occurring. The policy should also refer to the local guidelines so that staff know how to report a concern on to the Local Social Services department who are the lead agency. This will ensure that any concerns are dealt with appropriately. Some Staff have received training in the protection of vulnerable adults however staff recently appointed need to complete this training. Staff spoken with had some understanding of what to do in the event of a safeguarding issue occurring in the Home and how to protect people. Staff do require further guidance and support so that they know how to keep people safe and how to formally raise concerns with Social Care and Health. The finance records of the people living there were looked at briefly. Individual recording sheets are in place. Only one staff member deals with and signs the record sheets and people are not signing when they have received their money. Signatures should be sought from a witness where staff handles a person’s money and they are unable to sign. There were some receipts available but no system was in place for cross-referencing these to items purchased. Access to people’s money is restricted if the staff member responsible is not on duty so a system of signing and leaving money out for people has been set up. People who live there should be able to use and manage their money as and when they choose. The safe is stored in an unlocked cupboard. The arrangements in place for the handling and recording of people’s money must be reviewed so that clear, safe and accountable systems are in place that minimises any risk of financial abuse. Behaviour management plans and guidelines need some further development so that there is clear information on care plans for staff to follow about how to reduce this challenging behaviour. These should include diversion techniques so that people are supported to do things that are more positive. Recording made by staff about people in records and in meeting minutes were sometimes inappropriate and disrespectful to people. A 2008 diary was being used to record day to day information about residents this was not the appropriate place to record such detailed information. The manager has completed training about Mental Capacity Act 2005. The staff team had not yet received information or training on this. This is important legislation that requires an assessment of people’s capacity to be done if there is any doubt that the person does not have capacity to make a decision about Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 18 their health and welfare. If they are assessed as not having the capacity an Independent Mental Capacity Advocate (IMCA) can be appointed to help them with this. Staff should be aware of this legislation and the implications it has for people living there. Mrs Linda Nicholls DS0000004553.V344502.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. 26.30. Quality in this outcome area is adequate The home is comfortable and homely. Systems in place for the prevention of cross infection must be developed so that residents’ health is not put at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and well maintained and the AQUAA supplied to the Commission by the home prior to the inspection stated, “The home recently undertook redecoration in which the service users gave their input.” Residents spoken to were happy with their accommodation. Four residents’ bedrooms were visited they were individualized with personal possessions. The inspectors did not find any record in the residents’ files that they had chosen not to have furniture as listed in the national minimum standard. Paper towels are available in the bathrooms for residents to dry their hands. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 20 The inspectors were informed that laundry is now brought into the kitchen in linen baskets. The home has drawn up a laundry policy since the previous inspection this will have to be revisited, as it does not meet the standard. Staff were unable to find an infection control policy and procedure. One bedroom with an en-suite facility was visited. The bathroom carpet in this room looked tired and the room of emitted an odd odour. The tumble dryer was not working at the time of the visit, this must be addressed swiftly. Mrs Linda Nicholls DS0000004553.V344502.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. People are not supported or protected by the organisation’s recruitment processes. Staffing levels are adequate to meet the needs of residents. Staff are qualified and competent to meet the needs of residents This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was positive that staffing levels had been reviewed since the previous inspection. The rota indicated that there were now two staff on each shift, which ensures that there are adequate staff on duty to provide supervision and support. The rota must include staff member’s full details and role so that it is clear who is on duty supporting people. The previous inspection report raised concern about the Homes recruitment practice. The recruitment records for three members of staff were looked at. There were shortfalls on all three files. On the first file the recruitment records included an application form written references and while the POVA first check had been done (This is a check to make sure people are not on the list that bars them from working with vulnerable people) however the full CRB check Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 22 had yet to be received. On the second file there were no emergency contact details, the health assessment had not been completed, there were incomplete employment details and the application form had not been completed in full. The deputy said that the person’s referees had been contacted but there were no written references on file. On the third file there was no evidence that gaps in employment had been explored. The application form was incomplete. Recruitment practice is poor and does not ensure that suitable people are employed in the Home. Induction records were incomplete some sections had been completed and not signed and for some staff the induction programme was incomplete. The AQAA did not state what percentage of staff have NVQ 2 or above. Figures supplied to the Commission post inspection demonstrate that 60 of care staff have an NVQ2 or above in care. Information was received post inspection in relation to training. The process by which staff are supervised (structured and dedicated time set aside for staff) to receive support to do their job was discussed with the deputy manager. Supervision schedules seen indicated that whilst the deputy was on maternity leave formal supervision of staff was infrequent. Staff meetings provide an opportunity for staff to be informed of the changing needs of people and to promote current best practice in social care. Minutes of meetings seen indicated that meetings in the last twelve months had taken place infrequently the date of the last meeting was July 2007. Mrs Linda Nicholls DS0000004553.V344502.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. 42 Quality in this outcome area is adequate The homes systems do not fully ensure the safety and wellbeing of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current manager is also the registered owner and has been running the home for seven years. She is supported by an experienced deputy manager. The deputy manager assisted throughout the whole of the inspection visit. A number of health and safety records were looked at. Fire safety records showed that the fire alarm system and extinguishers are tested and serviced Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 24 as required so that it is kept in a safe working condition. The workplace fire risk assessment was in place along with individual fire risk assessments. Certificates were in place to show that electrical appliances, emergency lighting and gas equipment had been tested and serviced for the protection of service users. Water temperature checks are completed weekly to prevent the risk of scalding. The records seen all stated a temperature of 40c, which is a little unusual and the inspectors would have expected to see some variation at different outlets. The home has purchased a quality assurance system. Questionnaires have been sent out and four have been returned. These questionnaires are not aimed at specific user groups such as residents, families and professionals. Residents’ questionnaires need to develop so that they are relevant to the residents and in a format accessible to residents. As part of the quality assurance the home has purchased a manual containing policies and procedures. The management team have attended training in the new Mental Capacity Act legislation, which has led to the implementation of a mental capacity policy within the home. Whilst this is a positive step the policy only informs staff what the Act is about and does not give guidance as to how decisions can be made in relation to the Mental Capacity Act. As raised under the staffing standard the manager must ensure that the recruitment procedure is robust to protect residents. Staff were unable to locate the infection control policy which indicates that this document is not easily available to staff which is concerning. Personal development of resident’s independent skills needs to be developed, as identified under the lifestyles standard. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 25 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 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 2 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 1 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 2 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 2 X 2 X Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation 12(1) Requirement Timescale for action 30/04/08 2 YA34 YA37 Schedule 27,9 19 Residents with conditions such as diabetes or epilepsy must have a protocol in place to inform staff what to do if the residents condition changes. So that Health care needs of residents are monitored and any potential concerns dealt with appropriately The recruitment procedures 30/04/08 must be reviewed to ensure it is robust and that residents are fully protected. Previous timescale not meet 07/03/07 3 YA23 13 (6) Sch 4 The homes policies and 30/04/08 procedures must be reviewed in relation to residents’ money. The review must encompass such things as safe storage, a clear audit trail and residents accessibility to their own money when needed. Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations The Service User Guide should be reviewed and contain more pictures and photos so that the information is more meaningful to residents and each resident should be provided with a copy. Residents must have a written plan of care that describes how their needs in respect of health and welfare are to be met. Residents must be involved in the drawing up of theses care plans so their wishes and needs are fully explored and meet by the staff. Individual care plans must contain risk assessments, which are linked into the care planning process and are subject to regular reviews and staff must be aware of their content. Residents must be involved in drawing up these risk assessments. To attaché a review sheet to risk assessments to assist with there review. Residents must be supported to develop independent living skill, so that their opportunities to develop are enhanced. Residents must be informed of what is on the menu, on a daily basis, so if they wish to request an alternative they are able to do so. The home should contact its pharmacist and ask that residents who attend a day centre on a regular basis have their medication dispensed into a separate container, which they can then take out with them. This will minimize the need for secondary dispensing and the risk involved with this. The medication trolley should be chained to a wall for additional security. The homes written complaints procedure must be reviewed, so that residents, visitors and staff are clear as to how concerns will be dealt with and by whom. The home should explore alternative methods for residents to raise complaints and concerns. This will ensure residents are empowered to raise concerns. Records kept must conform to the data protection act, but must be written in an appropriate manner as to no be DS0000004553.V344502.R01.S.doc Version 5.2 Page 28 2 YA6 3 YA9 4 5 6 7 YA9 YA12 YA17 YA20 8 9 10 11 YA20 YA22 YA22 YA22 Mrs Linda Nicholls 12 YA23 13 14 15 16 17 18 19 YA23 YA23 YA25 YA30 YA33 YA33 YA39 deemed disrespectful to residents or staff members Residents’ behavioural guidelines and management plans must be developed. Residents must be involved in drawing up these guidelines so they can identify what they require from staff to meet these guidelines. It is recommended that the home obtain a copy of the Department of Health guidance “Mental Capacity Act 2005 core training set published July 2007. It is recommended that the home obtain a copy of the Department of Health guidance “Mental Capacity Act 2005 residential accommodation” published July 2007. Bedrooms should be audited against the NMS any shortfalls should be documented and kept under review. The guidelines for use of the washing machine and its implications in relation to cross infection must be reviewed as it does not identify how the risk can be reduced. Rotas must include full details of the staff member carrying out care of residents. Regular staff meeting must take place every two months to ensure that issues are addressed swiftly and a record of these meeting must be kept It is recommended that questionnaires sent out as part of the quality assurance system is tailored to the specific stakeholder in style and format this will ensure a better and robust response rate. It is recommended that the home review its policy and procedure in relation to mental capacity, as at present it does not guide staff in how to make decisions to comply with the Act. 20 YA40 Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mrs Linda Nicholls DS0000004553.V344502.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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