Inspection on 11/08/05 for St Albans Road (38)

This inspection was carried out on 11th August 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

St Albans Road (38) 01/02/08

St Albans Road (38) 10/08/07

St Albans Road (38) 27/06/06

St Albans Road (38) 14/12/05

St Albans Road (38) 10/03/05

St Albans Road (38) 18/05/04

St Albans Road (38) 14/02/04

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Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

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Polesworth Group 70 Long Street

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Ravenhurst

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 St Albans Road, 38 38 St Albans Road Moseley Birmingham B13 9AR Lead Inspector Joe OConnor Announced 11 August 2005 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 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 Stationary 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. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Albans Road, 38 Address 38 St Albans Road Moseley Birmingham B13 9AR 0121 449 3615 0121 449 3615 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Trident Housing Association Erika Lane Care Home 6 Category(ies) of Learning Disability - Physical Disability (6) registration, with number of places St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Karen Clarke will attend a course on managing challenging behaviour of at least 3 days in duration. The course syllabus should be approved by the NCSC. 2. Karen Clarke should complete her NVQ level4 in Management of care by June 2004. Date of last inspection 10 March 2005 Brief Description of the Service: St Albans is a purpose built detached, two storey building situated in a residential road in Moseley. The service accommodates six service users who have a learning disability, and a physical disability. Some service users have a behaviour that can challenge. The service is well situated for local amenities. There is a range of shops and Kings Heath shopping centre is close by as is Moseley village. The premises consist of six bedrooms with en-suite level access shower facilities. There is an open plan kitchen and dining room with good access for people with physical disabilities. Two communal areas are available one of which is utilised as a quiet room furnished with beanbags and easy chairs. There is a snoozelen room with a range of sensory equipment including fibre optic lights and lights. On the ground floor there is a communal bathroom that has a jacuzzi bath. The first floor is accessed via a passenger lift, with controls at a level people using a wheelchair can access. There is an office on the first floor and a sleep in facility is on the ground floor. This does not include separate staff bathing or toilet facilities. A separate laundry room is located at the rear of the premises. The rear garden has a patio area, which has recently been levelled and re-laid. The back garden is fenced and affords some degree of privacy. There is off road parking available. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over one day. The Inspector had opportunity to talk to one service user. There were a number of service users who had limited and no verbal communication and were unable to express their views on life at St Albans. Two members of staff were spoken with and care practices were observed. A tour of the premises was undertaken. Service users care records and risk assessments were inspected. Staff recruitment and training records were also examined a long with a number of health and safety records. The Inspector had opportunity to speak to the Registered Manager. Comments prior to this inspection were received from three relatives and one professional. What the service does well: Service users accommodation is clean, tidy and well maintained. A tour of the premises found that each service users has a bedroom decorated to their individual tastes and they also have their own possessions including videos, DVD, Stereo and TV. Some of the bedrooms have equipment that provides relaxation and stimulation with different coloured lights and objects. The bedrooms have en-suite showers that are accessible for people with mobility difficulties. Service users were observed to receive friendly and professional support from care staff. One service user nodded his head to say he was happy where he was living and thought the staff were nice. Comments were received from relatives before this inspection and they were positive about the care being provided. However, one relative did comment that communication from the staff could be better. Service users appeared well care for and dressed in clothing that reflected the climate of the day. Staff demonstrated an understanding of what service users could do, what help they needed and how they communicated. Three service users care records sampled found they were able to access GP, Dentist, Optician and Chiropodist. Service users are also able to access specialist healthcare professionals such as a Consultant Psychiatrist, Community Nurse, Speech and Language Therapist and other professionals such as Social Workers. A number of service users attend day services provided by social services and private organisations. Service users also have the opportunity to access activities in the community such as shopping, pubs, and Cannon Hill Park. There is a room called a Snoozelen that has relaxation music with different forms of light and sounds which one service user particularly enjoys. Service users are encouraged to be independent in cleaning their bedroom, laying and clearing the tables at mealtimes and their laundry. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 6 Staff receive regular training and a sample of staff recruitment and training records found that they receive training in important areas such as first aid, fire safety, manual handling, and food hygiene. Future training has been booked for staff to do awareness of autism and epilepsy. Staff receives supervision regularly and there have been no complaints about the service since the last inspection. What has improved since the last inspection? What they could do better: Each service user has a contract that explains they will have to pay for their accommodation but with one exception it does not cover whether service users have to pay towards the cost of transport. There is detailed information in service users care plans that identify the needs service users require assistance with. These will need improvement to ensure they set out how those identified needs are to be met. Service users have a plan of activities but these need more detail as to what exactly are the activities they are doing and evidence is required to show how service users’ made choices about the activities they were involved in. The manager has acknowledged that the activity plans need to be developed in a more accessible format. While there was evidence to show that service users were receiving check ups form various healthcare professionals, the records for these had not been updated by staff. Medication management needed improvement as one service St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 7 user prescribed soluble aspirin was not written up on the Medicines Administration Records or MAR charts as they are known. The medication procedure needed amending to say that medication errors must be reported to the CSCI. A service user who was identified as being on the adult protection register was overdue a review form their social worker and the manager was asked to follow this up. A number of policies and procedures were in need of reviewing and amending to ensure these reflected current law and practice. The complaints procedure needs to be developed in a more accessible format and the organisation must ensure the complaints procedure is made known to service users relatives as comments received before this inspection stated they were unaware of the organisation’s complaints procedure. One of the service user’s en-suite floor covering was in need of replacing. The dining room chairs need replacing as one service user was observed to be sitting on a chair but his feet were not touching the ground. 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. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 5 Service users receive detailed and clear information about the aims and objectives of the service and about the kind of service they will receive. The current needs of the service users are met with care staff providing positive support and have an understanding of their needs. Service users have a written statement of terms and conditions that informs them of the fees charged by the service but these will need to be updated with some minor improvements required. EVIDENCE: Since the last inspection the manager had addressed a requirement for the service user guide to include a summary of the statement of purpose. There were also details of the local CSCI office. A sample of service users’ records found that there had been a number of issues around service user whose behaviour had changed or were experiencing changes in their physical and mental health. It was evident that action had been taken to seek advice from specialist support services such as a consultant psychiatrist to review service users’ medication. One service user had been referred to a speech and language therapist over concerns he was having difficulty swallowing. Staff were observed to provide friendly and professional support and demonstrated an awareness of service users needs. Service users appeared to be well cared for and dressed appropriately for their age. One service user was able to provide some responses to questions about where he was living. This was mainly to nod his head to confirm that he liked living in the home, which St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 10 the staff was nice and he enjoyed the meals provided. Comments received from relatives prior to this inspection were positive. One relative wanted to thank the staff for all their support. Another stated that the manager had done a great deal to improve the communication between staff and the other relatives. However, one relative felt that communication could be improved otherwise the standard of care was excellent. An examination found that service users had a statement of terms and conditions and a licence agreement. However, the statement of terms and conditions did not state whether service users were expected to contribute towards transport costs. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9, 10 Service users needs are set out in detailed care plans that are reviewed regularly. Some improvements are required ensuring the care plans specify how the needs of service users are to be met. Service users are encouraged to make choices on a day to day basis using other means of communication where appropriate. Service users have risk assessments including how they should be supported in the service and when out in the community. Service users interests are protected by staff that understands the principles of confidentiality. EVIDENCE: Three service users care plans were examined and these contained detailed information around areas such as personal care, physical and mental health needs. There was detailed information about service users routines included on twenty four hour care plans. One care planned examined referred to a service user requiring structure and was particular about their daily routine. Another care plan referred to a service user communicates in makaton. While the care plans were detailed it was noted that one care plan did not refer to the fact that one service user uses a communication book with symbols as part of his daily routine. Another care stated that one service user needed regular exercising but did not state how this would be addressed. Each care plan did have a document called All About Me, which had a photo and pen picture of the St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 12 service user. The care plans had been reviewed and it was noted that these were updated to refer to any changes with service users’ health and behaviour. There are no formal service users meetings and the process of decision making is made on a day to day basis with the support of staff. The manger stated that she was trying to develop other means of involving service users such a developing a Velcro symbol board for service users setting out their activities and using photos of staff so service users can identify who is on duty. There were detailed risk assessments covering escorting service users in the community and for the management of behaviour. One risk assessment stated that a service user must not be left unattended when bathing due to their epilepsy. There was also a risk assessment regarding one service user who was prone to bruising due to deterioration with their behaviour that required staff to record incidents on a body chart. In discussion with staff it was evident that they had a good understanding around the need for maintaining service users confidentiality and the need for information to be shared only on a need to know basis. The organisation has a confidentiality policy and procedure. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16, 17 Service users are encouraged to develop their independence through appropriate means of communication for those with limited or non verbal means. Service users have access to leisure activities but work is required to ensure the weekly timetables are more detailed in what is being provided. In the community activities are age appropriate, and also service users receive organised activities with other agencies. Service users are not subject to any unnecessary restrictions subject to their individual risk assessment. Service users are encouraged to maintain contact with family and friends and positive relationships are maintained with staff providing a relaxed atmosphere. Service users are provided with a nutritious diet that promotes healthy eating. EVIDENCE: Service users are assisted to communicate their needs in different ways. For example one service user has a communication book where he points to pictures and symbols to express his needs and wishes. Two service users were observed to use makaton sign language. Service users’ care plans indicated that service users are encouraged to be independent in carrying out domestic tasks such as bed making and making drinks. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 14 Service users have access to daytime activities that are provided by the service and by the Local Authority and an independent provider. One service user had gone out with a member of staff to Cannon Hill Park for lunch. It was noted that each service user had weekly activities including trips out to the pub, walks in the local park and leisure activities indoors such as watching TV and listening to music and using the snoozelen room. These will need further development to ensure these fully reflect service users wishes. For example one entry referred to a service user watching a DVD but it did not state what exactly was the service user watching and to what kind of music were they listening to. Details of outings were also not specific as to where service users were going. Staff confirmed there were no unnecessary restrictions in place that the service users were free to do what they pleased. Service users routines were known and respected. A number of service users were observed to lay the table for tea and take their crockery into the kitchen. Menus provided with the pre-inspection questionnaire indicated that service users have access to a variety of nutritious meals. A record is maintained of what food had been eaten each day. A number of service users had eating and drinking guidelines in place that had been developed by a Speech and Language Therapist. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20, 21 Service users receive support with personal support and choose when they require assistance but improvement is needed in the recording of service users’ responses to support provided. Service users are able to access community and specialist primary healthcare services, but the records for such contacts were not up to date. Medication management is good with some minor improvements required in ensuring good health of service users is promoted. Consultation is still needed to ensure the final wishes of service users are sought and documented. EVIDENCE: One service user through nodding his head confirmed that he was able to go to bed and get up when he wanted to. Discussion with staff and from care records seen indicated that service users were able to have a lie in. A sample of service users records referred to where assistance was given to service users with their personal care. The daily recording of service users was in need of improvement so that there were more specific statements regarding how service users responded to the support they were receiving. There were risk assessments for the movement and handling of service users covering areas such as when they use the bath or shower. Service users are able to access the healthcare services in the community such as GP, Dentist, Optician and Chiropodist. However, it was noted that some of the records for such contacts had not been updated. There was evidence from St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 16 an examination of service users’ records that good relationships are maintained with specialist services provided by the Primary Care Learning Disability Trust. One comment received from a healthcare professional prior to this inspection stated that communication with the service was not always good and that reviews had been cancelled by staff at short notice. Service users’ weight was recorded every month. The management of medication was found to be good although it was noted that one service user prescribed soluble paracetamol did not have this printed on the Medicines Administration Record or MAR sheets, a dispensing error on the part of the supplying pharmacist but not picked up by staff. One service user had one of their morning tablets given but this had not been signed by staff. The medication policy and procedure was found to require amending to state medication errors must be reported to the CSCI and that details of the supplying pharmacist was required. An examination of staff training records found that staff had completed accredited medication training. A requirement from the previous inspection was for consultation to be undertaken regarding service users’ final wishes. One service users’ file sampled found that such details were in place but the other records viewed did not have any information regarding their final wishes. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 A complaints procedure is available but it must be developed in a format that is accessible for all service users. Staff have received training around the protection of vulnerable adults. The management of service users’ personal allowances is of an acceptable standard protecting service users’ interests. EVIDENCE: The organisation has a complaints procedure which, since the last inspection has included details about the CSCI including the address and telephone number of the local CSCI office. However, it does not state that no one will be victimised for making a complaint. The complaints procedure must be developed in a more suitable picture/symbol format for all of the service users. The manager stated that she was developing an idea for the complaints procedure to be put onto an audiocassette. Comments received from relatives stated that they were not aware of the organisation’s complaints procedure and action must be taken to ensure this is made available to them. Neither the CSCI nor the service has received any complaints since the last inspection. There is an adult protection policy and procedure that included information about organisations providing support for service users. There was an updated copy of the Multi Agency Guidelines published by Birmingham Social Care & Health. In addition there was a policy and procedure for physical intervention. A sample of staff training records confirmed that staff had received training in adult protection since the last inspection along with challenging behaviour and physical intervention. The management of person allowances were found to be satisfactory with a record of individual expenditure and for what purpose and final balances. Receipts were also maintained for individual expenditure. Those monies sampled were kept in individual purses or wallets and locked in a safe. Two St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 18 service users records sampled indicated that the organisation was acting as appointee while another stated that the service user’s parent was the appointee. Each service user has their own bank account. Two staff interviewed provided satisfactory responses that they would be able to challenge poor practice and report any incidents to the manager. An examination of one service users’ care records found that they were currently on the adult protection register and that a review of the individual’s circumstances was supposed to have been reviewed six months after the last case conference in November 2004. This is now overdue and the manager must ensure that review is arranged with the relevant social work team as soon as possible. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 The premises are accessible, clean and maintained to an acceptable standard with service users being able to move freely without any hazards. Service users bedrooms are personalised to their individual needs and lifestyles, providing adequate space for wheelchair users. There is adequate shared space available, which that is comfortable and accessible for all service users, but some improvements are required. The premises have suitable bathing facilities with appropriate aids and adaptations providing service users with assistance but also maintaining their independence. Staff observe appropriate infection control practices, maintaining service users’ well being. EVIDENCE: The premises were found to be clean, tidy and generally well maintained. A record is maintained of any repairs required. The pre-inspection questionnaire stated that since the last inspection two service users had new double beds and that the kitchen was fitted with a new gas cooker and microwave oven. There is a large dining room, which the manager admitted that it tended to look institutional as the service users sit on two sets of tables and was intending to have the furniture replaced as it was worn. It was noted that the dining room chairs were unsuitable for one service user whose feet were not touching the ground and action must be taken to replace the current tables St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 20 and chairs that is suitable for all service users. There are two lounges one of which is used as a quiet room with beanbags and cushions. The garden was found to be well maintained and can be accessed form the main lounge. Service users bedrooms were found to be spacious and provided enough for those service users with wheelchairs to turn round. An examination of the statement of purpose states that all the bedrooms meet the spatial requirements of the National Minimum Standards. The bedrooms viewed found they were decorated to individual tastes and one service users was found to have a range of multi sensory equipment. It was evident that most service users had their own possessions such as videos’ stereo and TV. The bedrooms had lockable facilities and the majority of fittings and furnishings. Each bedroom has a level access en-suite shower facility with toilet and hand wash basin. One bedroom had a call alarm pull cord and in the en-suite area. While the bedrooms were maintained to a good standard one of the en-suite shower floor was found to be in poor condition and needed replacing. Discussion with the manager found that a need had been identified for the service user who is male to have a urinal as he seemed to be unsettled using the current toilet facility. Despite this action must be taken to replace the floor and ensure the need for a urinal facility is addressed. The premises have suitable aids and adaptations including a shaft lift that has the buttons at a level that is suitable for wheelchair users. There is a mobile hoist and grab rails in the bathroom and en-suite facilities. A separate laundry is located to the rear of the premises and there is a washing machine that has a sluice programme and there is a sluice sink with a wash hand basin. There are appropriate facilities in place for the disposal of clinical waste. The bathroom and kitchen had liquid soap and disposable towels dispensers. Staff were observed to wear protective clothing when working in the kitchen. There are procedures in place for the control of infection. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36 Service users are supported by staff that have clearly defined job descriptions that enable them to undertake their roles and responsibilities effectively. The manager offers and provides staff training to all staff enhancing their development. Service users are supported by qualified and competent staff that demonstrates clear knowledge of the needs of the service users in their care. Recruitment records meet the requirements of the regulations, but amendments are required to the recruitment policy and procedure. Service users are supported by staff that receive regular supervision as part of their roles and responsibilities. EVIDENCE: Two members of staff interviewed including an agency worker, demonstrated a clear understanding of the needs of the service users in their care. Service users routines were known and respected. Three staff files examined confirmed that the training had been completed in areas such as food hygiene, manual handling, fire safety, health and safety and first aid. Staff had also received training in areas such as physical intervention, adult protection and challenging behaviour. The manager has arranged future training in areas such as epilepsy and autism. All staff had completed the Learning Disability Award Framework or LDAF programme as it is known and were awaiting copies of certificates. The pre-inspection questionnaire states that two members of staff were qualified to NVQ Level 2. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 22 Staffing levels at the time of this inspection were found to meet the needs of service users at the time of inspection with three staff on duty during the morning and four on duty during the afternoon and evening. With one night waking and one sleep in member of staff on duty during the night. Four members of staff had left since the last inspection, three having been transferred to other projects within the organisation and one retiring through ill health. The manager had recruited two full time staff including another night waking staff member and is recruiting for daytime support worker post. The pre-inspection questionnaire states that the service has taken on agency staff but the manager states that she endeavours to take on those agency workers who know the service users so there is little in the way of disruption to the service users. Staff recruitment records were found to be satisfactory. Three files sampled had information such as job description, induction record, contract, job application form, CRB check, two references, passport and birth certificates. Other information seen was medical questionnaires to confirm fitness for employment and equal opportunity monitoring forms. The manager had also information from various agencies regarding the agency staff covering shifts in the service. The information included details of the training completed by the agency staff and their CRB disclosure numbers. It was noted that the agency staff had completed induction records and had received supervision. In discussion with staff and from a sample of their records there was evidence to confirm staff were receiving supervision every two months. A sample of the organisation’s policy and procedure on recruitment was found to require some amendments such as that any gaps in the applicant’s employment history will be followed up and that the successful applicant will be appointed subject to two written references and a enhanced CRB and POVA First check. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42 Service users do not have a full time Registered Manager and the organisation must take action to address this and provide stability for service users and staff. There is an open relaxed friendly atmosphere that benefits service users and staff. Service users interests are reviewed and monitored by means of a quality audit system, with some improvements needed. The organisation has a wide range of policies and procedures that require review and amendments must be made to reflect current practice. Records being maintained were generally up to date and held securely protecting service users interests. The health and safety of service users is promoted and maintained. EVIDENCE: The service has been without a full time manager since May 2004 and a deputy manager on secondment from another service has covered the post. In discussion the acting deputy manager stated she would be returning to the other service as the Registered Manager and that another deputy would be seconded to St Albans Road. A representative from the organisation who was present during the inspection stated that the replacement deputy manager was St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 24 commencing training towards NVQ Level 4 in Management in September this year. The current arrangements for the management of the service cannot continue in the long term and the organisation must provide regular updates to the CSCI regarding the recruitment of a full time Registered Manager. The current acting manager demonstrated an understanding of the needs of the service users in her care and was keen to improve practice. Comments made during this inspection were received positively. She has worked hard to address most of the requirements from the previous inspection. At the time of this inspection the atmosphere was found to be friendly and relaxed. Staff spoken with stated they would be able to approach the manager if there were any concerns. An agency staff commented that the manager had helped her and other agency colleagues to feel part of the staff team and felt supported by her. Staff meetings do occur most of the time on a monthly basis. A representative from the organisation visits the service every month and detailed reports were available for inspection. A Quality Audit has recently been undertaken with the area manager for the organisation. It is recommended however, that the organisation develop anonymous satisfaction surveys for service users relatives, professionals and staff so they can contribute their views about how the service is performing. It was noted that a number of policies and procedures were due for review in some instances from June 2005. The organisation must ensure these are reviewed so that any amendments are made to reflect current practice and updated legislation. The records held in the service were generally up to date and locked in a secure facility. Records with regard to health and safety were found to be satisfactory. There was evidence to confirm that the fire alarms were being tested every week and the emergency lighting on a monthly basis. There was a risk assessment in place for the prevention of fire. A Fire Safety Officer had visited the service prior to this inspection and there was evidence to confirm that the manager had addressed the requirements issued during his visit. There was also documented evidence to confirm that a fire drill had taken place involving service users and staff. The accident book was examined and it was good to see there were no significant numbers of accidents since the last inspection. There was recorded evidence to confirm that the lift and hoist had recently been inspected and serviced. A current contract was in place for the shaft lift. There were risk assessments in place for the premises, food and a risk assessment checklist for the use of COSHH materials on the premises. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 3 3 Standard No 11 12 13 14 15 16 17 3 2 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Albans Road, 38 Score 2 2 2 2 Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 3 x E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 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 5 Regulation 5(2)(b) Requirement The Registered Person must ensure the statement of terms and conditions must clearly state whether service users are expected to contribute towards any transport costs. The Registered Person must ensure that service users care plans clearly state how the needs of service users are to be met including areas such as communication. The Registered Person must ensure that service users weekly activity plans reflect their individual choices. They must also provide specific details of the kind of activities undertaken. These must be developed in a more accessible format for service users. The Registered Person must ensure the daily recording of service users refer in more detail the responses of service users to support received and any reasons why this has been declined. The Registered Person must ensure that service users records with regard to contact Timescale for action 11 October 2005 2. 6 15(1) 11 October 2005 3. 12 12(3)(4) (b) 11 October 2005 4. 18 12(2)(3) 11 October 2005 5. 19 12(1)(a) (b) 11 October 2005 Page 27 St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 6. 20 13(2) 7. 20 13(2) 8. 21 12(1)(1) (a) (b) 9. 22 22(1) 10. 23 13(6) 11. 26 23(2)(b) (j) 12. 34 17(2) Schedule 4 with healthcare professionals are up to date. The Registered Person must ensure that the medication procedure is amended to state that any medication errors must be reported to the CSCI and it must also have details of the supplying pharmacist. The Registered Person must ensure that all prescribed medication is written on the Medicines Administration Records. The Registered Person must ensure consultation continues with service users, their relatives and other representatives with regard to ageing, terminal illness and their final wishes. Outsatnding Requirement. Timescale 1 May 2005 not met. The Registered Person must ensure that the complaints procedure is available in a format that is accessible for all service users. The complaints procedure must be made available to all relatives and other stakeholders. The Registered Person must ensure the service users identified are reviewed regarding their status on the adult protection register. The Registered Person must ensure that the flooring in the en-suite for the service user identified is replaced and that the need for a stand up urinal is addressed. The Registered Person must ensure that its recruitment and policy procedure is updated to state that sucessfull applicants will be appointed subject to an enhanced CRB and POVA check. It must also state that any gaps 11 October 2005 11 October 2005 11 October 2005 11 November 2005 11 September 2005 11 October 2005 11 October 2005 St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 28 13. 37 9(2)(b) 14. 40 17(3) in the applicants employment record will be followed up. The Registered Person must ensure that it provides the CSCI with regular updates regarding the recruitment of a full time Registered Manager. The Registered Person must ensure that as part of its quality audit system that it reviews its policy and procedures to ensure they reflect current practice and any legislative changes. 11 October 2005 11 November 2005 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 39 Good Practice Recommendations It is recommneded that the Registered Person develops anonymous satisfaction surveys for service users relatives, staff and professionals as part of the services quality audit system. St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 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 St Albans Road, 38 E54 S16928 St Albans V236023 110805 Stage 4.doc Version 1.40 Page 30 - 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. 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