Inspection on 20/02/07 for Selborne Mews

This inspection was carried out on 20th February 2007.

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 no outstanding requirements from the previous inspection report, but made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Selborne Mews 16/08/07

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 Selborne Mews 36-37 South Road Smethwick West Midlands B67 7BU Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 20th February 2007 08:30 Selborne Mews DS0000067092.V330234.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 Selborne Mews DS0000067092.V330234.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. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Selborne Mews Address 36-37 South Road Smethwick West Midlands B67 7BU 0121 555 5615 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) Selborne Care Limited Mr Kevin Taylor Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. As agreed with provider, a condition to be added which will limit the registration initially to 7 persons with a learning disability, to be accommodated on Fontwell Unit. To include care home (without nursing) to accommodate 6 persons with a Learning Disability on Exeter Unit. Date of last inspection Brief Description of the Service: Selborne Mews will eventually provide care for 20 service users in three separate units. At present Fontwell and Exeter units are registered with the Commission for Social Care to provide care for up to 13 service users with a learning disability. The home is unique in its design and enables service users to receive twenty four hour care and attention in the comfort of their own apartments. In each apartment service users benefit from a kitchen with a dining area, bathroom, bedroom and a living area. There are three two bedroomed apartments for those service users who wish to share accommodation. The home is situated close to Smethwick town centre and is accessible by bus and train. The homes aims to “work in partnership with the public sector and identified stakeholders to provide highly specialised and individual packages of care based on individual assessments and care programmes to enhance the lives and independence of the residents of Selborne Mews”. Charges for the home vary from £1600 to £2250 per week for residency at Selborne Mews depending upon individual care needs. this charge does not include extra services such as hairdressing costs, newspapers and magazines and telephone calls if service users choose to have their own private telephone line installed. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of this service since its registration in June 2006. it was completed by two inspectors from the Commission for Social Care Inspection (CSCI) and took 7 hours to complete. The judgments made in this report have been done so using available evidence, including information supplied to the CSCI by the home in their pre inspection questionnaire, using observations of care during the inspection and from talking to service users, staff and the manager throughout this inspection. Service user files were examined as part of the case tracking process, this means looking at care records in depth to determine whether the home is meeting the needs of its service users. Staff files were also viewed to ensure that the homes recruitment and selection processes are safeguarding service users. The inspectors would like to thank everyone for their hospitality throughout the day. What the service does well: Assessment processes are good, enabling the home to be confident it can meet the needs of people. All service user files sampled contained detailed information gathered from various sources. This information has then been analysed and incorporated into the homes global assessment of needs. All of the service users residing at the home live in self contained accommodation that includes individual kitchen facilities. This results in each person being supported to plan, prepare and cook their own meals (with support from staff), based on their individual needs and choices. Staff demonstrated good knowledge of promoting privacy and dignity, as one member of staff explained, “doors closed as much as possible, preferably covering as much as possible when assisting with personal hygiene. Respecting their space, if they want to be left on own in room”. The home provides a unique environment for service users, it enables them to enjoy the privacy of their own apartments and personal living space. Staff are recruited and selected in a manner that safeguards service users. All new staff receive an induction that introduces them to the home and the service users living in it. Staff feel supported by the manager and are confident that he will support them. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 7 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. Selborne Mews DS0000067092.V330234.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 Selborne Mews DS0000067092.V330234.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): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users receive good sources of information that informs them about the home enabling them to make a choice about moving into the home. Assessment processes are good, enabling the home to be confident it can meet the needs of people. People’s rights are not protected by the lack of comprehensive contracts. EVIDENCE: Pre-admission processes are good within this home. Service users benefit from a comprehensive Statement of Purpose and Service User Guide that clearly explains the working of the home and the service that can be expected once they have moved in. All service user files sampled contained detailed information gathered from various sources including discharge information from previous places of residency, care plans from previous establishments, psychology reports and assessments of needs from placing authorities. Information details needs including challenging behaviour, learning disabilities, health and psychology. This information has then been analysed and incorporated into the homes global assessment of needs. The home provides both residential and nursing care that is located in separate units within the home, with communal grounds Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 10 to the rear. Examination of records and observation of records indicate that the diverse range of needs of individuals currently residing at the home have the potential to impact on one another. When feeding back the inspection findings the manager was also instructed to ensure staff take greater care when completing assessment documentation, as some of this appears to contradict other information recorded. For example one persons assessment states they are not at risk from social isolation but then states they have no friendships or family. Evidence obtained through examination of documentation, talking to staff and indirect observations of practices indicates that the home is attempting to meet the assessed needs of people living at the home. However further work is required in particular with training and record keeping (see relevant sections of this report for further details) before the home can be confident it is meeting its obligations in this area in full. Generally staff that were spoken to demonstrate sufficient understanding of the communication needs of people living at the home. For example when asked about this replies included, “one knows some signs of makaton, as well if you hold objects or say something clearly he can respond and understand. Others are ok, can communicate, usually give a choice of things to do and prompt” and “when he try’s to say things people might not understand and this could cause frustration. With another he doesn’t communicate verbally, but can fully understand what you say. If people learnt sign language this would help, but some staff don’t understand this and this can cause problems”. None of the staff files sampled contained evidence that they have undertaken communication training specific to the needs of individuals living at the home. All new service users are encouraged to spend time at the home before they make the choice to move in. The length of time this takes depends upon the individual needs of the service users. This gives the both existing service users and prospective new ones the chance to meet and get used to one another. There are currently no contracts of residency in place between service users and the home. Selborne Mews DS0000067092.V330234.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): 6,7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems must be introduced that support individuals to become involved in decisions about their lives, and allow them to play an active role in planning the care and support they receive, within a risk-managed framework. Further improvements to some assessments of risk will offer greater protection. EVIDENCE: Three service users files were examined and found to contain care plans including aims and goals for identified needs including limited eye sight, bathing, community, wandering, agitated behaviour, walking without shoes, day to day needs, management of medication and loss of weight. Detailed daily records are completed by staff and care plans are evaluated monthly. When discussing the findings of the inspection with the manager he was instructed to ensure care plans are in place for all needs that have been identified during the initial assessment process. For example one persons Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 12 assessment states that they have epilepsy, although no seizures have been recorded since 1995, no care plan was found to be in place for this. It was also noted that some care plans in the residential unit are titled nursing plans. These need altering as the residential unit is not registered to provide this nursing care. When talking to staff none demonstrated sufficient knowledge and understanding of person centred planning and the principles and values that form the foundation of this approach to care. For example responses included, “don’t know about this” and “knowing about your client so can meet their needs, what they like and dislike and for them to live more independently”. The physical layout of the home, staffing ratios and care packages for individuals living there all support a person centred approach to care, it is therefore strongly recommended that care planning documentation and training for staff be introduced to support what is seen as current best practice for supporting people. Generally staff demonstrated knowledge and understanding of supporting service users to make decisions and offering people choices. For example one person explained, “different ways we do this, to find out what someone wants for breakfast can show pictures, when getting dressed again show different items of clothing, not too many though as they can get confused, we see what response they give, they may hold their hand out and touch or point” and another explained, “with one it’s a bit difficult because he doesn’t communicate verbally but he can understand what you say, so use pictures. With another he can tell you what he wants so it’s not a problem really”. Information relating to services in place at the home states that service user committees and meetings are used as forums for obtaining peoples views. Staff that were spoken to confirmed that currently these are not taking place. It is acknowledged that the home has not been open long and that only four service users currently reside there but action must be taken to ensure systems for systematically encouraging participation and decision making are in place. Further work required to ensure all areas of risk are assessed and recorded. All files sampled have assessments of risk for some identified needs such as falls, personal care, aggression and absconding but assessments for other identified needs as detailed in care plans are not in place. Practices observed and examination of records confirm that the home is meeting its legal obligations in relation to confidentiality. Selborne Mews DS0000067092.V330234.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): 12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally people living at this home are able to make choices about their life style, and supported to develop their life skills. Further work must be undertaken to ensure all people living at this home lead full and active lives based on their individual needs and expectations. All service users are encouraged to take part in meal preparation and enjoy a healthy diet. EVIDENCE: Activity plans were found to be in place on all service user files sampled but further work is required to demonstrate people living at the home lead full and active lives. For example all plans state that all service users tidy their rooms every morning before undertaking activities including shopping, playing games, going for walks to the park, and watching television. Every activity plan sampled stated that service users relax every evening, with none detailing any external activities. This was discussed with the manager who Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 14 informed the inspectors that the records do not reflect practices within the home, but that staff were not recording events accurately. As the people currently residing at the home have complex care and communication needs the inspectors were unable to validate this comment directly, reinforcing the need for accurate records to be maintained. The home was also instructed to introduce care plans for the management of activities in order that staff have clear guidance in this area. Evidence was found that attempts have been made to build relationships between individuals living within the home and staff who support them. For example one member of staff explained that she requested to work with a particular individual as she felt she would be able to encourage greater independence. Records also indicate that where agreed family contact and involvement is maintained. All of the service users residing at the home live in self contained accommodation that includes individual kitchen facilities. This results in each person being supported to plan, prepare and cook their own meals (with support from staff), based on their individual needs and choices. Records are maintained of meals eaten, however it is recommended that the home seek professional advice about the introduction of an assessment and screening tool, such as the Sandwell NHS Priority Screening Tool in order that service users needs are appropriately managed in this area. This is outlined in the National Minimum Standards. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 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. Medication practices within the home are safe and offer protection to service users. EVIDENCE: Staffs understanding of privacy and dignity is good. Privacy and dignity is respected at this home within a risk-managed framework. The majority of the people who live here require as a minimum at least one to one staffing, however the inspector observed that attempts are still made by staff to ensure privacy and dignity is respected. For example staff only entered accommodation upon approval of service users and wishes in relation to times of rising, bathing and mealtimes were seen to be respected. Staff demonstrated good knowledge of promoting privacy and dignity, as one member of staff explained, “doors closed as much as possible, preferably Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 16 covering as much as possible when assisting with personal hygiene. Respecting their space, if they want to be left on own in room”. Generally health care is appropriately managed. All files sampled contained evidence that people receive appropriate intervention from professionals including general practitioners and psychiatrists. Care plans for the management of psychological needs are in place along with other specific medical conditions. Other documentation in relation to healthcare management viewed includes Waterlow pressure sore risk assessments and manual handling reviews. It is strongly recommended that attempts be made by the home to introduce proactive, holistic approaches to healthcare management, with arrangements made for people living at the home to attend ‘Well Woman/Man’ clinics and to introduce screening tools such as the ‘Sandwell Priority Health Screening’ tool. Qualified nurses are responsible for administering medication within the nursing unit and team leaders within the residential unit. Some training has been provided from the supplying pharmacist however further work is required to ensure competency assessments are undertaken on a regular basis for all people (including nurses) to ensure practices are maintained to a satisfactory level and follow any relevant legislation. There are good systems in place for the ordering, receipt and disposal of medication. There are a couple of minor improvements that could be made to the process that would improve practice further, such as recording the exact dose given where a variable dose is prescribed, i.e. 1 or 2 tablets, and recording on the MAR sheet the amount of medication received from the pharmacy and signing it. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all people who live at this home are able to express their concerns, and have access to an effective complaints procedure. Staff have some knowledge of protecting people from abuse, however improvements to some policies and practices will offer greater protection and ensure peoples rights are protected in full. EVIDENCE: The people who live at this home have a variety of care needs and varying levels of communication that have the potential to impact on them being able to raise concerns. When discussing this with staff some informed the inspector that there is a client’s handbook that informs people of channels to go through in order to complain. However, despite the fact that the complaints procedure is displayed visibly throughout the home this is not in an accessible format for all people living there, other avenues such as residents and key worker meetings should be introduced that encourage and support people to complain. It is also recommended that concerns be set as a permanent item for discussion within staff meetings, in order that staff act as advocates for people living at the home who are unable to raise issues themselves. The home has received two complaints since it has been open, both of them have been responded to within given timescale of 28 days, the manager has recorded his investigations and outcomes, this shows an open and transparent approach to complaint investigation. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 18 All of the staff that were spoken to at the time of the inspection were able to give examples of abuse but none were able to explain their roles and responsibilities in relation to the protection of vulnerable adults (although many stated they had received training in this area). For example when asked about this responses included, “with the vulnerable adults you have to give them space, cant invade it” and “sorry don’t know off the top of my head”. The need for further training in this area was further reinforced when looking at the contents of the adult protection training staff had undertaken, as this appears not to include reference to local authority adult protection guidelines and procedures. The home was also instructed to review the adult protection policy, as currently it makes no reference to local authority adult protection guidelines. Some of the people living at this home have complex care packages to manage behaviours that can challenge, including physical and verbal aggression. Intervention policies and procedures are in place that appear appropriate, however improvements to training records must take place that evidence all staff working at the home hold up to date certificates or evidence of participation in “in house” violence and aggression training, as per the homes policy. When examining records relating to incidents of aggression and behaviour three incidents were found to have occurred that should have resulted in a referral to the local adult protection unit. No evidence of this happening could be found, with the manager confirming that he did not think this was required. This was discussed in detail, with the manager agreeing, in hindsight that referrals should have been made. Further work must be undertaken to ensure people living at the home are safeguarded and protected by the homes recording systems. For example incident forms instruct staff to record the build up/diffusion/de-escalation surrounding incidents but none of the records viewed had been completed for these areas, monthly summaries of events and incidents are in place that analysis events but some were found not to reflect the contents of incidents sheet and care plans for aggressive behaviour are in place but require further detail of actions to be taken by staff if aggression is displayed by one service user to another. The manager confirmed that he had recently received guidance from the Commission For Social Care Inspection relating to the findings of the Cornwall Enquiry. It is recommended that the home implements the recommendations contained within this guidance as further safeguards to vulnerable adults. It is positive that the home has worked proactively with the adult protection team on two adult protection investigations since the home opened. The management of finances is good within this home. No service users currently manage their own finances with advocates including appointeeship units undertaking responsibility in this area. Individual personal allowance sheets and receipts are maintained for each person within the home, all of which that were sampled were correct. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 19 Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a well maintained and hygienic environment EVIDENCE: A tour of the building was undertaken, it was pleasing to see that home is well maintained and that service users do benefit from having their own self contained apartments. All of the apartments have a kitchen so that service users can participate in preparing and cooking their own meals, a bathroom to maintain their privacy and their own individual living spaces. There are three two bedroomed apartments in total for those service users who choose to share accommodation. There is also a small communal meeting room where service users can relax with others and take part in leisure activity should they choose to do so. The home has a courtyard to the rear of the home that offers a place for service users to smoke if they choose to and to spend time outdoors, this area would however benefit from the addition of some furniture so that service Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 21 users can sit down should they wish to and it could be a more inviting place to be, at the moment it is sparsely decorated and looks uninviting. More recently the manager informed us that a maintenance worker has recently been employed to ensure that the current standard of maintenance and cleanliness is kept. The inspector witnessed a member of staff entering building with a service user who appeared to have some difficulty managing steps at the entrance to the home. It is recommended that advice be sought regarding the environment and external grounds in relation to the Disability Discrimination Act. It is also recommended that the home explore options for improving signage and access to the building as it took twenty minutes for the inspector to gain access to the building due to no-one hearing the call bell. There are individual laundry facilities in each apartment but staff do have a central laundry and sluice to access if needed, a few minor improvements would mean that service users are protected from the risk of cross infection, such as the production of a cleaning schedule that included the daily disinfection of all mop heads. The manager must also make sure that paper towels are available at all times, along with liquid soap to reduce the risks of infection to service users. Staff would also benefit from infection control training to improve both their knowledge and skills. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users can be assured that staff are recruited in a way that safeguards their interests and that there will be sufficient staff on duty to meet their needs. Improvements to training provided to staff are required to ensure that they have the appropriate knowledge and skills to support the people who live there. EVIDENCE: Six staff files were examined to make sure that the home is recruiting and training its staff appropriately. It was pleasing to find that all but one of the files contained the required information. One worker is still awaiting the return of their CRB disclosure, this has been an outstanding issue for many months, the manager has been in regular contact with the Criminal records bureau trying to speed this process along. The manager however, must ensure that when staff members are employed with only a PoVAfirst check in place, the worker is supervised at all times when working with service users and that a risk assessment is in place to demonstrate how service users are to be protected until any outstanding CRB’s are returned. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 23 Staff were asked to explain their roles and responsibilities as detailed within their job descriptions. Responses varied, with some people able to explain these in sufficient detail and others who should be give additional support. For example one person explained, “administering and ordering medication, care planning, hands on work with clients, planning activities, making appointments and maintaining records” and another, “to wear comfortable shoes, not big ear rings, not a lot of jewellery. No high heals”. Although some practices observed and discussions with staff indicate that they have some qualities and qualifications to support people living there improvements must be made in the provision of training (as mentioned in other areas of this report) in communication methods, physical aggression, physical interventions and person centred planning. Further work must also be undertaken to validate that the contents of training provided and that it is appropriate for the service provided. For example all staff files contained questions relating to various topics including fire, abuse, food hygiene, health and safety and first aid but no further evidence was available to confirm that individuals have been assessed as competent when having completed the questionnaires. This was discussed with the manager who stated that he scores staff and if they do not achieve a satisfactory level they have to retake. The inspectors explained that the home must be able to evidence this process. It was however pleasing to find evidence of induction that covers administration, policies and procedures, principles of care, needs of service users and safety at work. Records confirm that staff meetings take place on a monthly basis, this being above the National Minimum Standard for Younger Adults. The home is staffed by qualified nurses and support workers, 4 of the support workers have achieved their NVQ level 2 and a further 3 are working towards completion of theirs. Staffing levels appear appropriate to the needs of people living at the home. The majority of staff files sampled contained evidence that they have received at least one formal supervision session in order that they are supported to undertaken their roles. This was discussed with the manager at the time of the inspection, who explained that most staff have recently finished their induction process and have been getting to know the service users, plans for supervision are going to be improved in the near future. This is a new service and has not been open for a year yet, therefore there have been no annual appraisals of staff but the manager did confirm that this would happen. This will help identify staff training and development needs. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is well managed and generally run in the best interests of service users. The home needs to demonstrate further involvement of service users in its quality assurance systems to ensure that it is operating in their best interests. EVIDENCE: The manager of the home is Mr Kevin Taylor he is a registered mental health nurse (RMN) and has many years of experience both working in a hospital setting and more recently social care. Mr Taylor is a qualified trainer and uses his skills to train staff on a regular basis. During discussions with Mr Taylor it is clear to see that he is enthusiastic about developing the home into a place where service users achieve their goals and aspirations. There is a quality assurance system in place, this includes the regular auditing of the environment, medication, and care planning, the manager also audits Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 25 untoward occurrences, accidents and incidents. This will help identify any trends that may occur and allow the manager to formulate an action plan to reduce any risk to service users. What needs to happen is that the manager must demonstrate how they involve service users in this process and show that the home is run in the best interests of the service users it cares for. As mentioned in other areas of this report some policies and procedures require reviewing to ensure they comply with legislation, practices within the home and are up to date. It is also recommended that policies relevant to service users be included as set item on service users meeting agenda, to encourage and involve them in decision making processes. In the main service users rights and interests are safeguarded by the homes record keeping practices. When examining other documents the inspector found that notifications to the CSCI in line with Regulation 37 of the Care Home Regulations 2001 have not been completed. This was discussed with the manager, who confirmed his commitment to ensure this does not continue. As mentioned earlier in this report the majority of staff have received some training in food hygiene, however further support is required for some staff. The inspector witnessed a member of staff bringing hot sandwiches from one part of the building to a service users residency, putting the uncovered items on the floor in courtyard. The manager was also informed that action should be taken to change the designated smoking area for staff as this is currently in the courtyard at the rear of the premises, in sight of service users. It is recommended that advice be sought from the Environmental Health Department regarding smoking and legislation that is due to take effect from July 2007. All staff that were spoken to demonstrated understanding of their roles and responsibly in relation to moving and handling and health and safety. For example one person stated, “don’t lift if possible. Test before attempting to lift, don’t carry boxes or heavy objects, you need to assess situation” and another, “you are responsible for the safety of yourself and the clients, make sure the place is safe to work, do all required checks, log faults”. All of the required safety checks and maintenance certificates were spot checked and found to be in order Selborne Mews DS0000067092.V330234.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 2 4 3 5 2 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 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 2 2 2 2 3 Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Not applicable 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 YA3 Regulation 18(1)(a) Requirement Timescale for action 01/05/07 2 YA5 3 4 5 YA6 YA9 YA13 The home must be able to demonstrate that staff have suitable skills and knowledge to communicate with all service users. 19 The home must ensure comprehensive contracts of residency are in place that contain all required information as detailed in the Care Home Regulations 2001. 15 The home must ensure comprehensive care plans are in place for all identified needs. 13(4)(6) The home must ensure risk assessments are completed for all identified needs. 16(2)(m)(n) The home must be able to demonstrate that service users lead full and active lives, based on their individual needs and capabilities. The home must introduce care plans for the management of activities. The medication must be reviewed to ensure that all parts of it are relevant to the care practices within the home. DS0000067092.V330234.R01.S.doc 01/05/07 01/05/07 01/05/07 01/05/07 6 YA20 13(2) 01/05/07 Selborne Mews Version 5.2 Page 28 Where a variable dose of medication is recorded staff must indicate which dose they have administered. Staff must record on the MAR sheet all incoming medication and sign it. The home must introduce systems for supporting service users to raise issues and complaints, appropriate to their assessed needs and capabilities. All staff must receive further guidance in relation to adult protection. The adult protection policy must be amended to include instructions as per the local authority adult protection guidelines. The home must follow the local authority adult protection guidelines at all times. Any potential abuse must be referred to relevant agencies as per the local authority adult protection guidelines. Detailed and comprehensive records must be maintained for all incidents of violence and aggression. Care plans for the management of aggressive behaviour must be expanded and include actions to be taken by staff if aggression is displayed by one service user to another. All staff must undertake aggression and physical interventions training. The registered manage must DS0000067092.V330234.R01.S.doc 7 YA22 22,24 01/05/07 8 YA23 13(6) 01/05/07 9 YA23 13(6) 01/05/07 10 YA23 13(6) 01/05/07 11 YA30 13(3) 01/05/07 Page 29 Selborne Mews Version 5.2 introduce a cleaning schedule for the laundry and sluice rooms, 12 YA33 18(10(a) The manager must be able to demonstrate the steps to be taken if staff do not meet the required standard following training ,this will ensure that staff are competent and have the required knowledge and skills at all times. The manager must ensure that all staff who are awaiting a CRB disclosure have an risk assessment in place , that shows how service users will be protected during this time. 01/05/07 13 YA34 19 01/05/07 14 YA39 24 15 YA40 19, 24 16 YA41 19, 37 The staff member must be supervised until the outstanding CRB is returned. The home must be able to 01/05/07 demonstrate how service users are involved in their quality assurance process. The home must ensure policies 01/05/07 and procedures comply with legislation, practices within the home and are up to date. The home must ensure that all 01/05/07 records required by regulation are maintained within the home and are up to date. The home must ensure CSCI is notified of any incident as detailed in Regulation 37 of the Care Home Regulations 2001. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 30 No. 1 2 3 4 5 6 Refer to Standard YA2 YA2 YA6 YA7 YA17 YA19 Good Practice Recommendations That the homes pre-admissions assessment documentation be expanded to include a comprehensive assessment of compatibility with others. That an audit of information gathered from other sources be undertaken with any duplicated or out of date information archived. That person centred plans are introduced. That staff receive training in person centred planning. That service user meetings, the allocation of key workers and advocates are introduced. That the home seeks advice in relation to nutrition and diet and introduces an assessment and screening tool. That the home introduces proactive, holistic approaches to healthcare management. That the Sandwell Priority Health Screening tool be obtained and implemented. That concerns be set as a permanent item for discussion within staff meetings in order that staff act as advocates for service users. That the complaints policy is updated to remove references to the NCSC and provide the CSCI Halesowen address . That the CSCI recommendations in relation to the Cornwall enquiry be implemented. That advice be sought regarding the environment and external grounds in relation to the Disability Discrimination Act. That the home explores options for improving signage and access to the building. That all staff receive at least six supervision sessions per year. That annual appraisals are introduced for all staff. That policies relevant to service users be included as a set item on service user meeting agendas. That advice be sought from the Environmental Health Department regarding smoking and legislation. 7 YA22 8 9 YA23 YA24 10 YA36 11 12 YA40 YA42 Selborne Mews DS0000067092.V330234.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Selborne Mews DS0000067092.V330234.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. 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