Inspection on 27/06/06 for St Albans Road (38)

This inspection was carried out on 27th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Albans Road (38) 01/02/08

St Albans Road (38) 10/08/07

St Albans Road (38) 14/12/05

St Albans Road (38) 11/08/05

St Albans Road (38) 10/03/05

St Albans Road (38) 18/05/04

St Albans Road (38) 14/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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) Moseley Birmingham West Midlands B13 9AR Lead Inspector Joe O`Connor Unannounced Key Inspection 27th June 2006 09:15 St Albans Road (38) DS0000016928.V298227.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 St Albans Road (38) DS0000016928.V298227.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. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Albans Road (38) Address Moseley Birmingham West Midlands B13 9AR 0121 449 3615 0121 449 3615 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) Trident Housing Association Vacant Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Date of last inspection 14th December 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 limited off road parking available. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over one day. The Inspector spoke to one service user, one member of staff and two relatives were interviewed following this visit. Service users care records were examined and risk assessments were also inspected. Care practices were observed. Staff records and those for health and safety were also sampled. The Inspector spoke to the area manager and deputy manager for the service. Additional information was also examined in what is known as a pre-inspection questionnaire that is sent out to the home before the fieldwork visit, along with copies of reports written by the organisation of their monthly visits to the home. To compare how the service has performed since the last inspection then this report should be read with the previous unannounced inspection report 14 December 2005. The service has a set weekly fee of £810:00 What the service does well: What has improved since the last inspection? The CSCI was very concerned for the welfare of the service users at 38 St Albans Road at the previous inspection in December 2005. Since then the service has made improvements to address many of the requirements from the last inspection. There were only three full time staff vacancies at the time of this inspection, which the area manager commented would be filled following a recent St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 6 recruitment event. The home still relies on taking on agency staff but these are now part of the staff rota who the area manager feels works well with the people living in the home and are reliable. When examining the staff training records a number had commenced what is known as accredited medication training in March this year. Staff were receiving more supervision, which was taking place every two months. Each service user has an individual health action plan that includes information about their healthcare needs and the appointments they had to see a doctor, dentist, optician and chiropodist during the year. Service users’ weight was being recorded every month. The management of medication had improved since the last inspection. Guidelines for service users having when required or PRN medication were written up and signed by their GP. The area manager has been developing a complaints procedure into a more easy to understand format. New systems were in place to enable staff understand what to do if they suspected abuse was taking place in the home. This included a record where staff have to record any unexplained bruising or marks they notice on the service user. A revised adult protection procedure was in place. Improvements had been made to the information documented in the care plans and risk assessments. Staff are now reporting incidents to the CSCI that affect the welfare of the service users such as falls and where any medication had not been given. What they could do better: Parts of the building including the dining room and kitchen would benefit in being re-furbished so that it improves the quality of life for the service users, as the décor looks very worn and tired. One of the service users care plans stated that staff should have training in epilepsy awareness but this had not been addressed. The care plans must show more evidence whether the service user was involved in their development and review. Staff need to make sure that service users are supported with their personal appearance, which should be maintained to an acceptable standard. Improvements are still needed to ensure the daily records are completed on a daily basis by staff to confirm service users are being supported with their personal care. The range of activities available for service users must improve and the daily records must reflect what service users had been offered and participated in. The service users must be given opportunity to prepare meals in the home within a risk assessment framework. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 7 The manager no longer works for the service and it is important the organisation recruits another to provide the service users with much needed stability. 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) DS0000016928.V298227.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 St Albans Road (38) DS0000016928.V298227.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome is adequate. This judgement has been based on available evidence including a visit to the service. Improvements are still needed in ensuring the service is able to meet the needs of the current group of service users. Service users have up to date contracts informing them what they have to pay for their accommodation. Service users needs are currently being reviewed with social work assessments on file. There is up to date information about the service, which is being made more accessible for service users. EVIDENCE: Some improvements were observed since the previous inspection in how staff were interacting with service users although one agency staff on duty was unsure as to how to assist one service user who was trying to show his communication book. Another service user was observed to be hitting himself quite hard and it had taken a while before staff had spoken to him to find out what was wrong. It was noted that the service user was given a child’s toy as a means of distracting him, which was not appropriate. Since the last inspection the area manager stated two service users had been re-assessed by Birmingham Social Care & Health and a sample of one of the service user’s care records found there was a copy of a Single Assessment document. Two service users were due for review but Social Care & Health had not been in touch with the service to arrange the reviews despite the area manager being told these would be carried out. The area manager stated that St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 10 the organisation has been working hard in improving the service being provided and has been making arrangements to link up with the service users day services to improve communication to share any concerns and develop positive relationships. The area manager provided copies of an updated statement of purpose and service user guide, which are being developed in a more accessible format for the service users. The will include the use of illustrations and symbols. There are new contracts in place, which include information about any transport costs to be covered. St Albans Road (38) DS0000016928.V298227.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome is adequate. This judgement is based on available evidence including a visit to the service. Improvements have been made with the development of service users care plans setting out how their needs are to be met, but these must confirm their involvement in their draft and review. Service users have risk assessments identifying how they should be supported in the home and in the community. EVIDENCE: Three care plans were sample during this inspection. Each service user has a care plan that covers their routine over a twenty four hour period. An additional section had been added including information about the mannerisms and personality of each service user. One referred to the service user as enjoying talking and having 1:1 support from staff. Another care plan seen referred to the importance in letting the service user choose what to wear during the day and that he enjoys watching Laurel and Hardy films. One care plan seen did contain some information about the service user using a box of items to communicate but in discussion with the deputy manager this was not the case. It also referred to what distraction techniques should be used when supporting the service user to manage their personal care because of the individual’s short concentration span. The care plans had been reviewed since St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 12 the last inspection. It was noted however, there was no evidence confirming whether the service users had been involved in the development and reviews of their care plans. Risk assessments were in place, which included how the service users should be supported in the home and in the community. There was a detailed risk assessment on file for two service users which stated they should on no account be left alone to together due to their unpredictable behaviour. There was also a risk assessment for the prevention of choking. Another risk assessment also stated that a service user should not be left alone when having a shower because of the possibility of a seizure due to the individual having epilepsy. Since the last inspection the area manager has introduced a communication passport with illustrations and easy to read sentences to provide basic information as to how each person should be communicated with. It also includes their name and date of birth. How effective these have been in improving communication will be assessed at the next inspection. The area manager should consider other means of illustrations such as photographs. The area manager stated that following a meeting with Birmingham Social Care & Health prior to this inspection, the organisation would be working with an external organisation in developing person centred plans for each service user. It was noted that since the last inspection there had been improvements with staff not entering personal care details of service users in the staff communication book, addressing a requirement from the previous inspection and ensuring the privacy and dignity of service users. Due to the complex needs of the service users living in the service there are no formal service user meetings. One person has recently attended a tenants meeting within the organisation where he can meet other people from the other services provided by the other organisation. The service user nodded his head and said yes when asked if he found the meetings useful. While this is acknowledged as a positive step there was not enough evidence to show whether those service users with non verbal communication were being involved in the running of the service. An examination of service user’s daily recording provided some examples where staff had made reference to service users choosing their clothes when getting dressed. A sample of service users personal allowances indicated service users had their own individual bank accounts although there were nominated people within the organisation who sign for any withdrawals. The pre-inspection questionnaire stated two service users were subject to Guardianship with regard to the management of their finances. St Albans Road (38) DS0000016928.V298227.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome is adequate. This judgement has been made based on available evidence including a visit to the service. Service users records do not provide enough information with regard to the activities chosen by service users. Improvements are needed with regard to the recording of food eaten by service users confirming they are receiving a varied choice of meals. Service users are supported to maintain contact with their relatives. EVIDENCE: Two of the service users attend a day service provided by an independent company while the remaining group go to local authority daycentres. There was some evidence indicating service users were involved in activities in the home including artwork and there were paintings and drawings by service users on display around the dining area. There were England flags in the living room for the World Cup which one service user said he was looking forward to England’s next game. Each of the service users had activity plans that used illustrations. The organisation must give consideration in developing the use of photographs and symbols so that these are more accessible for those who are unable to verbally communicate. An examination of the daily records found that the activities planned for service users did not reflect what service users St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 14 did. Most of the entries still referred to service users “spending time in their room”, “listening to music” or “watching TV”. Some entries also stated “went out or went for walk” but with no reference as to what they the service user was doing. The area manager acknowledged there were still issues around the quality of activities being provided and was working with staff to be more creative in providing a wider range of activities. The issue has also been picked up during her monthly visits to the service. One relative commented that she felt her son should be doing more in the way of activities, which was not often enough. The area manager commented that it is hoped the service users will be able to go on holiday in the coming months once a stable staff team is in place. One service user has already asked about going to Disneyland. There was some recorded evidence where service users had recently been to Sea Life Centre, pub lunches, while one regularly attends a multi sensory facility at Moseley centre. There is a multi sensory room in the building which one of the service user’s was using during this visit. There was also some evidence confirming service users were able to maintain contact with their relatives. One goes out with his father regularly at the weekends. Another has visits from his mother who has recently purchased a new wardrobe on his behalf. One of the service users recently had a birthday party where relatives of the other service users had been invited at his request. The management team raised concern regarding one service user who attends a local authority day centre who was having hours reduced. The reasons given by the centre were that the transport staff were concerned about the individual’s behaviour, which was “putting them off”. As a result the service user has only been out for as much as two hours and is returned to the home. In discussion with the management team it was evident they were trying to resolve this issue with the centre. An examination of three service users care plans covered their daily routines over a twenty four hour period. There were tick lists charts were in place to indicate where service users had been involved in domestic chores including, laundry, bed making, dusting and cleaning their bedrooms. It was noted none of the care plans had made any reference as to whether the service users were able to manage a key to their bedrooms. A sample of the food menus for the previous four weeks indicated improvements had been made to the range of meals available to service users. However, there was not a complete record in evidence of the meals eaten by service users, particularly if any service user had not consumed any of the menu choices available. An examination of the daily records and in discussion with a staff member and area manager found most of the service users were involved in the food shopping. Staff were observed to encourage service users St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 15 to prepare their own drinks although there was no evidence to confirm whether any of them were involved in any meal preparation. Guidelines were in place for service users who had eating and drinking requirements. One service user was observed to have specially prepared textured drinks and reference was made to individual’s specific needs on the care plan. A risk assessment was also in place regarding the need for the service user to have soft food and textured drinks. The area manager stated that another service user with renal problems was undergoing a change in his dietary requirements and that staff will be having training with regard to this. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 18, 19, 20, 21 Quality in this outcome is poor. This judgement has been based on available evidence including a visit to the service. Service users care records are not completed consistently to show they are receiving the required support with their personal care and observation it was offered as required. Improvements are being made to with regard to the arrangement and management of service users’ healthcare needs. Medication management has improved promoting and maintaining service users’ good health. Service users are being consulted with regard to their final wishes. EVIDENCE: Three care records sampled found that each service user had a manual handling assessment and these had been reviewed since the last inspection. The current group of service users are male and the staffing is provided by a predominantly female staff team. The organisation has developed a gender care policy since the last inspection, which was in a format with illustrations. There was also a policy and procedure in place for the promotion and maintaining of personal relationships for people with learning disabilities. However there must be some reference made in the service users’ care plans regarding their gender care preferences. Further examination of the records indicated there were still examples where staff had not made any entries in daily recording notes to confirm where service users had received support with their personal care. Some entries referred to “all care given”. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 17 An issue was raised with the deputy and area manager at the time of this inspection. This related to how one of the service users was presented. The service user had returned from his day service and it was noted his T-shirt was covered in stains. None of the staff on duty had approached the service user to support him with his personal appearance. This also happened with another service user who had spilt some of his tea while trying to drink it. Comments received from one relative said that during a recent visit to the service she was concerned as to her son’s personal appearance who was not always well presented particularly with the condition of his hair. There were some examples where staff had referred to service users choosing their clothes when getting dressed and choosing to have a lie in. The area manager acknowledged this was still an issue which needed improving and was committed to improving practice in this area. There were records in place where staff had ticked to confirm which aspects of personal care service users were involved with and bowel monitoring charts were seen to be up to date. Since the last inspection each service user had a health action plan, which included details of recent appointments to see a GP, Optician, Chiropodist and Dentist along with a record of their weight. However, one of the plans did not make any reference to the service users’ skin condition and how it was being treated. There had been improvement with the recording of service users’ weight and the area manager stated that one was being weighed at the dietician clinic at Greenfields. One service user had a programme of exercises for which were not always completed by staff to confirm these had been completed. The same individual’s care plan made reference to the fact he had no teeth but there was no evidence to indicate whether the service user had been offered an oral check to monitor the condition of his mouth and gums. The management of medication had improved since the previous inspection. An examination of the Medicines Administration Records indicated there were no gaps in the recording of medication being given. The service has introduced regular staff medication audits and there was evidence confirming where medicines had been administered correctly and highlighted any errors. There was evidence from staff records that any issues around poor medication practice were being addressed by the management in a robust manner. There were photocopies of the prescriptions attached to the MAR sheets. Protocols for the use of PRN medication had been reviewed by the service users’ GP. Staff training records confirmed that the majority of staff had commenced accredited medication training since the last inspection. An issue was highlighted with the area manager concerning one service user who was prescribed paracetamol in a box. There was no record confirming how many tablets had been carried over from the previous MAR sheet cycle. The tablets were prescribed for PRN but no protocol was in place for this. The medication procedure had been amended to say that the CSCI were to be informed of any medication errors. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 18 A requirement from the previous inspection for consultation to take place with regard to service users’ final wishes had been undertaken with one to be completed through a multi disciplinary meeting as the service user does not have any relatives. In discussion with the management team they mentioned that one of the service users had recently lost his best friend. The service user has no verbal communication and the management team were looking at ways to help the service user maintain some memories of his friend through the use of photographs. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 19 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 the following standard(s): 22, 23 Quality in this outcome is good. This judgement has been based on available evidence including a visit to the service. Service users are being provided with a complaints procedure, which is being made into an accessible format. Improvements have been made to protect the interests of service users, with systems in place for the reporting of suspected abuse. EVIDENCE: The CSCI had received one complaint since the last inspection, which the preinspection questionnaire stated, was upheld. This was from a relative concerned as to the cleanliness of her son’s bedroom. There is a record maintained of complaints received. A complaints procedure has been drawn up in widget style format with illustrations. Suggestions were made to the manager to use photographs to make it more accessible. A photograph of the Inspector was on display in the dining area. The organisation has made improvements in developing training and guidance for staff in ensuring their awareness and responsibility around the protection of vulnerable adults. A flowchart has been drawn up informing staff what they should do if there are concerns regarding the welfare of service users. This information had also been given to agency staff. Each service user now has a record where staff record any unexplained bruising. A copy of the multi agency guidelines published by Birmingham Social Care & Health was available. The area manager stated that a revised adult protection procedure had been drawn up and was due for publication. Since the last inspection a number of staff had received training in adult protection, challenging behaviour and physical intervention. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 20 An adult protection referral had been made by the CSCI to Birmingham Social Care & Health prior to this inspection. This involved two service users who had been left alone in the lounge and one had assaulted the other. At the time of this inspection there were detailed risk assessments in place for both service users stating clearly that they should not be left alone. The area manager had spoken to the social work team informing them that the risk assessments had been reviewed and the staff on duty at the time of the incident would be taken through the organisation’s disciplinary procedure. The Inspector spoke with the team manager for the social work team who expressed satisfaction in how the service had addressed the concerns and agreement was reached to close the adult protection referral. One member of staff interviewed stated he would be able to challenge poor practice and report any concerns to the management. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 21 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 the following standard(s): 24, 30 Quality in this outcome is poor. This judgement has been based on available evidence including a visit to the service. The premises would benefit in being re-furbished ensuring service users have a more homely environment. EVIDENCE: The premises was generally clean and tidy at the time of this inspection. There was some evidence indicating work was in progress to replace the dining room furniture, which was being ordered through a company called Keep Able. It was noted however that part of the premises such as the kitchen and dining area would benefit in being re-furbished as the paintwork and décor was tired and worn. The deputy manager commented that the kitchen in particular needed some new kitchen units. There were holes in the ceiling of the dining room because of problems with a leaking shower in one of the bedrooms. So far the problem with this had not been addressed. A requirement from the previous inspection for a urinal to be installed in one of the service user’s bedroom had been addressed. The floor in the en-suite facility had been replaced. The deputy manager stated that since the last inspection one of the service users had a new wardrobe and new bedding had been supplied for all service St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 22 users. There are also two service users who are being supported to choose designs for astro ceilings providing images of their favourite pictures or logos. The laundry area was found to be in need of cleaning on the ceiling as there were cobwebs and the extractor fan was in need of cleaning. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome is adequate. This judgement has been based on available evidence including a visit to the service. Service users are receiving a consistency of care and support with appropriate numbers of staff on duty. Improvements are required in ensuring service users are supported by staff who are trained to undertake their duties effectively. Staff receives regular supervision as part of their training and development. Staff recruitment practices require some minor improvements to protect service users’ interests. EVIDENCE: The pre-inspection questionnaire indicated that the service did not have 50 of its care staff qualified to NVQ level 2 or above which the service should have achieved by 31 December 2005. An examination of the staff training records indicated staff were receiving training in mandatory topics such as first aid, manual handling, health and safety, food hygiene and adult protection. Staff had also commenced training in areas such as challenging behaviour, awareness of autism and Equality and Diversity. Discussion with the area and deputy manager highlighted the need for staff to undertake training towards LDAF. It was noted that one service user care plan referred to the need for the staff to undertake training in epilepsy that had not been addressed. Since the last inspection two members of staff had left the service and the area manager stated the organisation was short listing to recruit three full time members of staff. The pre-inspection questionnaire stated that in the previous St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 24 eight weeks 168 shifts had been covered by agency staff. The area manager commented the service is still dependent on agency staff but has began to include a number of regular agency staff as part of the rota to promote consistency for service users. An examination of the staff rotas indicated different agencies were being used. The rota indicated there had been a review in the levels of staffing during the evenings from four to three. This was a result of a review of two service users who no longer required 1:1 staffing. The Registered Provider must ensure the revised levels are monitored regularly to ensure the service users concerned are not at any future risk. The area manager stated she was committed to ensuring service users had continuity of care and support during the day and that any agency staff who were found to be performing poorly would not return to the service. This would sometimes create difficulties in trying to arrange for agency staff to cover shifts, as the service has to maintain appropriate staffing levels. Three staff recruitment records were examined and there was evidence confirming appropriate documentation was in place including job application form, contract, and proof of identity, CRB checks two references, induction record and contract. CRB check details had been obtained by the service for agency staff. At the time of this inspection two agency staff were being inducted by the deputy manager. There was evidence confirming agency staff were completing induction checklists. The records for the agency staff that are part of the staff rota will require additional information regarding their proof of identity. The area manager has been co-ordinating with the full time staff team to bring in their certificates of training and qualifications. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 Quality in this outcome is adequate. This judgement has been based on available evidence including a visit to the service. Service users need stable management support to maintain progress in making improvements. Service users health and safety is maintained with some improvements needed. Some improvements are still needed in maintaining service users’ care records that are up to date every day. Monthly visits by a representative from the organisation meet the requirements of the regulations. EVIDENCE: The inspection was undertaken with the co-operation of the area manager and deputy manager. In discussion the area manager stated that the Registered Manager had his contract of employment terminated because he had not performed to the level expected of the organisation. The area manager stated she would be providing management cover for the service while a replacement is being recruited. She also acknowledged that while improvements had been made there was still much work to do in ensuring service users had a wider range of activities and improvements were needed with staff documenting how service users were being supported. Comments made during this inspection St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 26 were received positively. An examination of staff records indicated there was swift action being taken in addressing issues of poor practice through the organisation’s disciplinary procedure. One member of staff stated he would be able to approach the management support and advice and there were monthly staff meetings. One relative spoken with following this inspection expressed satisfaction with the care and support provided for his son, but was concerned that the service seemed unable to retain a manager for any length of time and that there were not enough full time staff. Another relative also expressed concern as to the lack of stable management and that there were different staff on duty. In discussion with the area manager it was stated work was being undertaken to develop a quality audit system including the use of satisfaction questionnaires, which were currently being drafted. There were reports available of monthly visits undertaken by the area manager and these were detailed in their content and highlighted any areas of concerns, which needed addressing. Since the last inspection monthly reports by the then manager had been sent in providing an update on progress being made in addressing the requirements from the previous inspection. The area manager provided examples of policies and procedures, which the organisation has been reviewing since the last inspection. Generally the records held on the premises were up to date and locked away in the office. However, improvements are still required in ensuring service users’ daily records are completed on a daily basis. Records with regard to health and safety were on the whole satisfactory. There was evidence confirming the fire alarms were being tested every week and the emergency lighting every month. The risk assessment for the prevention of fire had been reviewed and there was documentary evidence confirming that the equipment used for fire fighting had been serviced. The area manager provided information confirming staff would be undertaking training shortly in fire safety. It was noted however, a fire drill had not occurred for over six months and an immediate requirement was issued for this to be addressed. A requirement for the lifting equipment used in the home to be serviced had been addressed. There was also evidence confirming that a portable appliance test had occurred prior to the inspection and there was an up to date Gas Landlords safety certificate. The service had recently received an inspection from Environmental Health and no requirements were issued. The lift had also been serviced prior to this inspection. At the time of this inspection it was noted there were no materials left unattended used under COSHH Regulations. A risk assessment was in place for the premises. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 27 The accident book was examined and it was noted only three had occurred since the last inspection. There have been improvements with the service notifying the CSCI of any incidents affecting the welfare of service users under Regulation 37. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 28 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 N/A 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 2 STAFFING Standard No Score 31 N/A 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 3 LIFESTYLES Standard No Score 11 N/A 12 2 13 2 14 N/A 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 2 3 2 N/A 3 3 2 2 N/A St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA18 Regulation 12(2)(3) Requirement Timescale for action 27/07/06 2. YA3 YA18 12(1)(a,b) 2 3 4(a,b) 5(a) The Registered Person must ensure the daily recording of service users is completed in full on a daily basis after each shift. The recording must confirm the care and support service users receive and reflect the activities participated in by service users. Outstanding Requirement. Timescale 14 January 2006 not met. The Registered Person 27/08/06 must ensure that service users personal appearance is maintained to an acceptable standard, which respects their privacy and dignity. Appropriate means of communication equipment must be tried in assisting service users with non verbal communication skills. The Registered Person must ensure service users DS0000016928.V298227.R01.S.doc 3. YA13 12(3)(4)(b) 27/09/06 St Albans Road (38) Version 5.2 Page 30 4. YA18 12(3)(4)(a,b) 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 current format should include the use of photographs rather than illustrations. Outstanding Requirement. Timescale 11 October 2005 not met. The Registered Person 27/08/06 must ensure service users care plans must make reference to their gender care preferences. The Registered Person must ensure all Individual Health Action Plans refer to specific healthcare conditions. 27/09/06 The Registered Person must ensure it provides the CSCI with a plan of future refurbishment and decoration, evidencing how the premises will be maintained to a safe, presentable standard. The laundry area must be cleared of dust and cobwebs and the extractor fan must be cleaned The Registered Person 27/09/06 must ensure all staff are registered for training towards LDAF. The Registered Person 27/08/06 must ensure additional proof of identity is obtained for agency staff who are part of the staff rota. DS0000016928.V298227.R01.S.doc Version 5.2 Page 31 5. YA24 YA30 23(2)(b) 6. YA32 18(2) 7. YA34 19(1)(b)(i) 17(2) Sch2 St Albans Road (38) 8. YA35 18 (2) 9. YA37 9(1) 10. YA41 17(2) 11. YA42 13(4) 12. YA16 12(3)(4) The Registered Person must ensure that all staff undertake training in epilepsy. The Registered Provider must recruit a qualified and competent manager. They must make application to register with CSCI. The Registered Provider must make adequate interim management arrangements and up date the CSCI. The Registered Person must ensure service users care records are up to date and reflect their current needs. The Registered Person must ensure all staff undertakes a fire drill that must occur every six months. The Registered Person must ensure any reasons why service users should not have a key to their bedroom is documented on their care plans and cross referenced to their individual risk assessments. The Registered Person must ensure it maintains a record of food eaten by service users particularly where they have eaten an alternative to what was available on the menu. Service users must be given the opportunity to prepare their own meals. 27/08/06 27/08/06 27/08/06 04/07/06 27/08/06 13. YA17 16(2)(i) Sch4(13) 27/08/06 St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 32 14. YA7 YA8 12(3)(4) 15. YA20 13(2) The Registered Person must demonstrate how all service users are involved in the running of the home. The Registered Provider must ensure Protocols are in place for all medication prescribed as PRN. Outstanding medication balances from the previous month must be recorded on the new MAR charts to confirm what has been carried over. 27/08/06 27/08/06 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 YA39 Good Practice Recommendations It is recommended that the Registered Person develop anonymous satisfaction surveys for service users relatives, staff and professionals as part of the services quality audit system. Outstanding Recommendation. St Albans Road (38) DS0000016928.V298227.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Birmingham 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) DS0000016928.V298227.R01.S.doc Version 5.2 Page 34 - 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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