Inspection on 05/08/08 for The Dell

This inspection was carried out on 5th August 2008.

CSCI found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Dell 10/02/09

The Dell 12/06/07

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/11/2008.

CARE HOME ADULTS 18-65 The Dell 30 Monument Avenue Wollescote Stourbridge West Midlands DY9 8XS Lead Inspector Jean Edwards Key Unannounced Inspection 5th August 2008 7:40am The Dell DS0000069594.V369529.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 The Dell DS0000069594.V369529.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. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Dell Address 30 Monument Avenue Wollescote Stourbridge West Midlands DY9 8XS 01384 826050 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) Select Health Care (2006) Limited Vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only Care Home only to service users on the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disability (LD) 7 The maximum number of service users to be accommodated is 7 Date of last inspection 02 April 2008 Brief Description of the Service: The Dell is a large detached property, which provides accommodation for up to seven people with learning disabilities. It is a privately owned care Home, which is part of Select Healthcare Limited. The Home is situated in a quiet residential locality in the Wollescote area of Stourbridge and is within walking distance of the local village, which has shops, public houses, a park and other local amenities. The town centre of Stourbridge can be accessed by public transport. There is a small parking area at the front of the building and a patio and garden at the rear of the property. There is no lift access for residents. It 7 single bedrooms. There are lounge and dining room facilities on the ground floor together with a conservatory. The Home has bathing facilities on the first floor and a very small en suite in the ground floor bedroom. There are toilet facilities sited throughout the Home. There are limited car parking spaces at the front of the home. Access is via a steep drive, which has been improved with handrails, ramps and steps. There was no information relating to fees contained in the service user guide. For information about fees that the home charges you are advised to contact the Home Manager. Additional costs include hairdressing, toiletries and private chiropody, which can be provided within the home for an additional fee. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We, the Commission for Social Care Inspection (CSCI), have undertaken an unannounced key inspection visit. This means the home has not been given prior notice of the inspection visit. This inspection was undertaken over one day, with two inspectors spending a day at the home from 07:40 to 20:15 hours. All Key National Minimum Standards for adults aged 18 – 65 years have been assessed at this visit. The range of inspection methods to obtain evidence and make judgements included: discussions with the acting manager, the supervisor, senior and support staff on duty during the visit, discussions with residents, observations of residents without verbal communications and examination of a number of records. Other information has been gathered before this key inspection visit including notification of incidents, accidents and events submitted to the CSCI. The home’s Annual Quality Assurance Assessment (AQAA) was submitted to the CSCI on 25 May 2008, prior to this key inspection visit. Although we sent CSCI survey forms to the home to be distributed none were returned prior to the inspection or date of this report. We took a tour around the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents’ bedrooms, with their permission, where possible. We sent CSCI surveys to the home to be distributed and returned in order that people could give us their views about the home. Unfortunately none were returned. The quality rating for this service is Zero stars. This means the people who use this service experience poor quality outcomes. What the service does well: The people living at The Dell were able to choose when to be alone in their own bedrooms or when to join others in the communal areas. The staff showed respect for residents’ privacy and allowed them to choose whether or not they wished to take part in any activities. We saw how attentive some individual members of staff were towards some of the residents. One resident was encouraged and supported to maintain his independence and goes out into the community on his own. Some residents continue to attend local day centres and college placements to develop their skills and knowledge. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 6 Some residents told us they liked the food. One person told us, “The food here is good.” We saw staff had made the effort to ensure that food was freshly prepared and appetising. There were dishes of fresh fruit available for residents to help themselves as they wished. Residents’ bedrooms were generally decorated and furnished to suit each person’s age and individual tastes. Bedrooms were homely with lots of personal belongings. What has improved since the last inspection? What they could do better: We carried out a random inspection in April 2008 to investigate a serious allegation and to monitor action to show the required improvements were being put in place. The registered person was issued with requirements for immediate improvements particularly to maintain safe staffing levels and rigorous recruitment of staff. These requirements were to ensure that the provider would take action to make essential improvements to the way care was provided and risks were managed. The random inspection report also included actions the registered person must take to improve the way new staff were recruited and agency workers were used, with more rigorous checks. We took this course of action to make sure residents’ health, safety and well being would be protected. At this key inspection we found that the registered person had not made the required improvements and in some areas such as the recruitment and essential staff training there had been a serious deterioration. We have reissued immediate requirements to maintain safe levels of trained, experienced, competent staff to make sure residents’ health well being and safety can be assured. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 7 We had highlighted at the previous inspections the registered person, acting manager, senior carers and staff must all recognise when potential episodes of abuse have occurred; and they must refer to the multi agency safeguarding team and work within Local Authority protocols. We found that there were incidents, and records of events, which the acting manager had not referred to the Local Authority, as required. This does not give assurances that residents will be safe from risks of harm. Following this key inspection we have written to the registered person and acting manager, informing them that we have referred various incidents to be investigated under the safeguarding procedures. The home must provide clear and accurate information in appropriate formats to prospective residents and representatives so that they can make realistic choices about where they wish to live. We had identified at the random inspection that resident’s care records must be more detailed and reflect all residents’ individual needs, choices and capabilities. The written information must provide staff with comprehensive instructions how each person’s needs should be met. The home’s routines must be arranged around the resident’s choices and preferences, not around the number of staff available. The poor quality of records of care, and medication, for people with changing needs, in particular, must be improved to offer confidence that the care needed is actually provided. Additional advice and support must be sought from the health care specialists and community dietician for any residents were assessed as being at risk of poor nutrition or losing weight. The required improvements have not taken place, particularly with regard to written risk assessments, to support all residents to take risks thereby developing their quality of life and assure they are safeguarded from identified hazards. The systems for resident’s prescribed medication must be reviewed and improved urgently. This is to make sure all residents receive the medication as prescribed by their GP for their health and well being. The systems, which were in place to monitor residents’ activities to meet each person’s preferences, had deteriorated. In addition there were not sufficient numbers of staff on duty to enable residents to have access into the community to undertake stimulating and individualised activities. The routines of the home were task based and not person led. The residents’ were not supported in decision making processes to make informed choices. The organisation must make improvements to ensure that residents are supported to lead fulfilling lives based on their individual needs and capabilities. The programme of redecoration and refurbishment needs to be completed so that residents can live in a safe and pleasant environment. There were a number of areas of serious risk, such as excessively hot radiators and The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 8 unsecured cupboards, with utility meters and cables, accessible to residents and a damaged and frayed bedroom carpet, which posed a tripping hazard. Staff must be provided with specific training to meet the needs of residents. This should include person centred approaches to care, autism, epilepsy, challenging behaviour, moving & handling and fire training, and safeguarding adults as priorities. Risk assessments were of poor quality and do not offer effective control measures to manage and minimise risk to the residents, they must be improved so that residents’ health and safety is maintained. The management arrangements at the home were not effective and the quality assurance systems did not ensure that residents’ views were taken into account or help to shape the service provided. There were some areas of health and safety, which have serious consequences, and other areas were not effectively managed and continued to pose serious risks, which compromised residents’ safety and wellbeing. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 9 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 The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is adequate. The home has comprehensive assessment documentation so that holistic assessments can take place. New and existing residents could be assured their individual needs would be measured and met if it were used effectively. The home’s statement of purpose and service user guide are not up to date, which means that people do not have access to accurate information to help them make decisions about their choice of home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager submitted the home’s AQAA (Annual Quality Assurance Assessment) to the CSCI on 25 May 2008. It contained the following information about what the manager claimed the homes does well: “We have a Statement of Purpose and Service Users Guide, which are reviewed and kept up to date”. We asked the acting manager about progress to meet the previous recommendations to revise and update the information given to people about the home. She told us that the required details of additional charges with regard to some items of toiletries to be made more explicit in the service user guide and residents’ contracts had not been actioned. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 11 We looked at copies of the home’s Statement of Purpose and Service User Guide. There contained a list of activities but the acting manager stated the home was not actually undertaking these activities at the present time. She told us this was largely due to staff shortages. The details in the Statement of Purpose included the previous registered manager’s name, who retired in September 2007. The contact details for the CSCI address were also out of date and the acting manager confirmed that the documents need some updating with correct information. The Statement of Purpose was not in a format suitable for people living in the home to understand but the Service User Guide was in a pictorial format. The level of fees charged for this service was not published in the service user guide and individual fees were not recorded as part of each person’s contract of residence. From examination of a sample of residents’ care records we noted that one person did not have a contract on file and another person’s contract/statement of terms and conditions was dated 29/03/93, though there was a review held, which was dated 31/05/07. There had been no new admissions to the home since the last inspection visit; however there had been a recent death and therefore the home now had a vacancy. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is poor. Care plans have not been updated to provide staff with sufficient guidelines to meet the needs of residents. There has been no further progress enabling residents to participate in identifying their needs and aspirations through person centred planning. Risk assessments have not been reviewed or developed to ensure all potential hazards are identified and minimised, in order to demonstrate that residents are enabled to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the previous key inspection in June 2007 and the random inspection on 2 April 2008, we saw care plans, which were well organised, clear and covering a wide range of topics. There was some development needed and recommendations were made for the manager to introduce care plans for management of challenging behaviour. We recommended keeping the care plans simple and person centred, writing them in the first person wherever The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 13 possible and using easy words and pictures. We also recommended that referrals should be made to speech and language therapists for assistance in developing communication passports. The home’s AQAA submitted to the CSCI on 25 May 2008 included in the information about what the homes does well, with the statement, “We have developed care plans with the prospective residents and their relatives, the carers and key workers. We encourage the service users to take a greater part in the homes decisions. The evidence claimed to support the statement was, “Person Centered Plans”. We looked at a sample of two resident’s care and support in depth and a sample of aspects of other resident’s support and care. We noted that very little had changed since the previous inspection. We discussed the lack of progress with the acting manager who had been in post since September 2007. She acknowledged that the previous requirements had not been actioned. We could find no evidence of care plans or meaningful risk assessments for the management of challenging behaviours. This was despite accident records, ABC Incident records and daily progress records demonstrating an escalation in incidents of physically aggressive behaviour between residents and towards staff at the home. We could not find any referrals for speech and language support for the two people without good verbal communication skills and the acting manager acknowledged to us none had been made. At the random Inspection on 2/4/08 the acting manager stated that she was making progress to improve the care plans, demonstrating with the file of one resident. She stated that a lot of the information had been archived and that she was attempting to make the care plans and risk assessments more detailed. The residents’ care files we saw still contained large amounts of ‘old’ information, which had not been archived or reviewed since April 2007. The information was not summarised and did not provide easy to follow guidance for staff. This was particularly important because of the high numbers of new staff and agency workers, needing accessible, understandable information to know residents needs and preferences. No further progress had been made to produce care plans in formats suited to each resident’s abilities, such as symbols, pictorial and easy read. Some examples of the lack of progress with care planning, we noted on one resident’s care file were: any change of behaviour, signs of seizures, dated 10/01/06, there was no review date. Going to lunch and shopping, was dated 26/11/05, with a review date 16/05/07, but no further reviews or information. “To encourage X’s living skills, dated 10/05/06 with a review date 26/02/07, but no information about what had been achieved. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 14 We looked at the support being provided for the two people who do not have any verbal communication. The acting manager acknowledged that there was no written information or communication care plan to support staff in understanding each person’s use of gestures or body language. She told us that referrals had not been made to the speech and language therapists for support to develop appropriate communication aids for these residents, as had been strongly recommended at the previous inspections. We asked the small number of staff available what was happening to support resident’s to develop individual and fulfilling lifestyles and they told us that due to continued staff shortages residents were mainly being supported as a group, there was very little time to spend with residents on an individual basis. A previous recommendation had been made to review, update and expand written risk assessments to ensure that any unnecessary risks to the health and safety of residents were identified and so far as possible eliminated. We asked the acting manager what progress had been made to achieve the required outcome of improved independence and improved safeguards for residents. She told us that she had not had sufficient ‘admin time’ to undertake this work, saying that the majority of time she was working on shifts as part of the care team, providing direct care and support for the residents. We examined the accident records, and ABC Incident Analysis records, which were confusing because not all accidents or injuries had been recorded as such. We noted that from November 2007 to the date of this report there were 14 accident records. It had been recorded that one person had fallen whilst trying to sit down 5 times but there was no written assessment of risk or measures recorded to try to avoid or minimise this happening on a repeated basis. The staff had recorded, “did explain to X that she needs to sit properly on chair”. There were also 3 further falls whilst attempting to sit on a chair recorded on the home’s ABC Incident analysis records, between December 2007 and May 2008, but not recorded as accidents. For example, “X came from across the room to sit next to staff when she sat on a corner and slipped off chair and fell she was shocked and then she got up and cried left elbow was a bit grazed and red X was checked and chose to sit back in chair again. The action recorded by the senior member of staff was, it was explained to X that she needs to be careful when she sitting on a chair. There were also records of unexplained injuries and marks especially relating to three residents, which were not recorded in the accident records, referred for medical advice, investigated or reported through the safeguarding procedures. We discussed these omissions and concerns with the acting manager and supervisor and it was clear there was a lack of understanding about the definition of an accident, incident or episode of challenging behaviour. The lack The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 15 of action poses serious risks to the health, safety and well being of residents at the home. We were told that one person’s family had recently approached the home with their solicitor, to work with the home to ensure a more fulfilling lifestyle, utilising his finances in his best interests. However there was no documentary evidence on this person’s file, to date. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 16 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is poor. The opportunities for residents to engage in social and recreational activities have seriously decreased due to high staff turnover and staff shortages. Residents are encouraged to maintain important links with their families. Residents can make some choices with regard to their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA sent to the CSCI on 25 May 2008 included in the information about what the homes does well, it stated, “We have a daily one-to-one meeting with 1 resident and encourage her to develop her communication skills. We play dominoes with residents. One resident has a bus pass and is encouraged to use it regularly and independently. The service users are facilitated to access other methods of transport other than the homes minibus. 1 Service user has an identity card for when he is attending courses at college. This The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 17 document is fiercely protected by him. Service users use a local bank/building society to withdraw their personal allowance. Service users go to the Pear Tree centre and participate in activities. Residents go to local restaurants or pubs for meals. The residents go on holiday. We go out shopping and encourage service users to do their own shopping e.g. choosing clothes, shoes and toiletries. The service users go to the theatre, parties and other social events. We allow residents to help themselves in the kitchen when it is safe to do so e.g. bringing plates and cups in after a meal and make a cup of coffee or tea We arrange for in house entertainment at the home. We accompany service users to the hairdresser. We maintain regular contact with the service users relatives who are also encouraged to visit them at their home or come to The Dell. The residents have a meal of their choice.” The evidence presented in the home’s AQAA was, “Person centre plans, Care planning, Risk assessments Service users activities folder” At the key inspection in June 2007 and the random inspection April 2008 we were told that the residents could go food shopping and help prepare meals, although we did not see any actual evidence of these activities. At the time we spoke with one resident who told us that she liked to go to the day centre and enjoyed a cooking activity. She had told us she did not cook at home but she would like to. We recommended that meal preparation and cooking are included as an option on residents’ activity menus. As highlighted at the previous section of this report the acting manager acknowledged no further progress had been made with person centred planning and risk assessments. We looked for evidence claimed in the home’s AQAA in resident’s activity planners and folders but found that activities had seriously declined. In addition some of the information in the AQAA about what the home claimed to do well was inaccurate and misleading. There were only two staff on duty during the morning of this key inspection visit and the 6 residents were unable to go out of the home. The day care provision provided by the Local authority was not available for the two week close down for the annual holiday. There were no planned activities scheduled in house or at external venues for residents, either as a group or individually. The driver handy person had taken the minibus to do the large weekly shopping at ASDA. No residents participated as part of daily living activities and staff told us this was the usual practice because of staff shortages. The supervisor told us two resident’s might have been interested in going but there were not enough staff available to go with them and “X needs 2:1 staffing when we go out”. We looked at the minibus log sheets from 24/6/08 – 5/8/08 and noted usage for transport of residents to day centres – Amblecote, Peartree Lane, and hospital. Usage for shopping trips but not whether residents were present; and just a one outing – 19/7/08 “ride out to Enville”. We also saw that the minibus had been loaned to another home in the The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 18 organisation, used for the residents’ holiday at that home from 29/6/08 – 6/7/08. We looked at the care plan aims for two residents, one indicated, “Going to lunch and shopping, dated 26/11/05 with a review date 16/05/07. To encourage X’s living skills, dated 10/05/06 with a review date 26/02/07, nothing was recorded since these dates. This person’s general activities menu showed activities for X, “Sunday – morning=church or watch service on television – afternoon=looking at books; Monday – morning=Keeling Centre – afternoon=arts/crafts Tuesday – morning=library – afternoon=lunch out/foot massage Wednesday – morning=ride to Himley Park – afternoon=short walk Thursday – morning=Pear Tree – afternoon=help tidy bedroom and look at books Friday – morning=Keeling Centre – afternoon=personal shopping Saturday – morning=walk – afternoon=karaoke. The only recorded entry for activities was in the daily records, dated 19/05/08 “Went to Keeling Centre”. We looked at a risk assessment relating to this resident where 6 ABC records of physical aggression and challenging behaviour had been completed. This was entitled “Job Safety Analysis”, which was dated 4/11/05 and signed by the previous registered manager. This had not been reviewed since 9/5/07. The risks assessed were in relation to this resident’s personal safety in the community. The risk control required was, “to ensure personal safety by being accompanied by a trained member of staff was in the community who has CRB and POVA clearance. X is never to be left alone or unobserved whilst in the community. The carers to have senior’s permission to leave the home with X, and this is to be recorded. If lost or incident occurs carer must call the home or the “on call” for assistance immediately.” We discussed the lack of activities with the staff and acting manager. Two members of staff interviewed told us that this person requires a minimum of two staff, when out of the home because of the behaviour she exhibits. We discussed the number of staff needed for this person to go out into the community with the acting manager and she initially told us that the resident could be managed by one member of staff, but commented that some staff are “frightened of the residents.” Later in the inspection the acting manager described an incident when she had taken the resident to the local shops. She told us that, after buying and eating chocolate the resident had refused to walk with her, dragging her into the middle-of-the-road. We asked if this incident was recorded or if she could remember when it had occurred. The acting manager told us that she could not recall the date, and from an examination of records there did not appear to be a record of the incident described either in the residents daily statements or the ABC Incident analysis. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 19 There was a similar menu of social activities for another resident, Sunday morning=church or watch service on television – afternoon=ball games/ride in countryside – Monday morning=ride out to garden centre – afternoon=musical instruments – Tuesday morning=short walk – afternoon=foot massage – Wednesday – morning=ride out in countryside – afternoon=mood music to relax and sensory lights – Thursday – morning=Pear Tree – afternoon=listening to music – Friday – morning=shop at Merry Hill – afternoon=musical instruments – Saturday – morning=ball games – afternoon=karaoke. There was no recorded evidence that any of these activities had taken place since May 2008. During this inspection visit we re-issued an immediate requirement for the staffing levels to be increased to ensure there were sufficient staff available to meet each resident’s health, safety and socialisation needs. The acting manager came on duty early to assist with the inspection process and she contacted a senior member who was rostered for a day off, who abandoned her arrangements to be on duty. At 12:50 we noted that the supervisor was engaged in washing dishes in the kitchen, the support worker was mopping the dining room floor and the senior carer was observing the residents sitting who were in the lounge and conservatory. One resident was quite excited because she thought the senior had come to the home to take her shopping. The senior, who had told us she had arranged to come in especially take the resident (in her off time) the following day, placated her by explaining the plan for the next day. We saw confusing information about the resident’s annual holiday, we were initially informed there were plans for resident’s to have individual holidays of their choice, which would be very positive. However during discussions with staff we were told that there had been some discussions about 2 separate group holidays for residents and this had been changed to one large group holiday, at a holiday camp, due to take place in August 2008. We asked who had made the decision and chosen the location. Two staff told us this holiday had been decided by the acting manager and a recently appointed support worker and they were not aware of any resident consultation or involvement. We were not shown any evidence of how the decision had been reached when we discussed the holiday arrangements with the acting manager. We asked the acting manager how the holiday was being supported and funded. She told us that five staff would be accompanying the six residents and that the organisation was funding half of the cost, with residents contributing half themselves. We were concerned to learn that the resident’s accounts had been debited for the total cost of the deposit and after discussing amounts shown on the invoice it was evident that resident’s were being charged for the staff accommodation on holiday. We assisted the acting manager with the calculations and made a requirement for resident’s to be reimbursed for staffing costs. The acting manager agreed to ensure this was carried out. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 20 One resident went out unaccompanied during the afternoon of the inspection and showed us his new haircut on his return. A member of staff commented that her relative, who was a hairdresser usually came to the home to cut the resident’s hair. We did see evidence from the accident records and ABC incidents that relatives had visited the home. We saw evidence that residents could choose what they wanted for each meal, and there was a varied range of food stocks available. We noted that there were bowls of fresh fruit freely available for residents to help themselves. We did not see evidence of how residents were supported to choose healthy meal options and the home had not taken any action to be assessed by the NHS PCT /Environmental Services healthy eating awards for care homes. We recommended that the acting manager contact the community dieticians and awarding agency for free advice, training and support to assist residents to choose healthy lifestyles. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 21 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, 21 Quality in this outcome area is adequate. Residents cannot always be assured of receiving personal support in a according to their preferences, due to inconsistent staffing arrangements. The health care needs of residents are not always comprehensively reassessed, which means that any potential complications could be overlooked. Arrangements for management of medication are not properly monitored, which pose risks that residents may not always receive their medication as prescribed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s AQAA submitted to the CSCI on 25 May 2008 included information about what the homes does well, it stated, “The residents have undertaken a Health Action Plan with the Health Liaison Nurse, The residents have Flu injection every year, The Consultant Psychiatrist regularly reviews the residents medication and liaises with the GP, Trained staff dispense medication The pharmacist visits to conduct regular audits, The Residents have a Screening Priority.” The AQAA also gave the following information about how The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 22 the home had improved in the last 12 months, “The residents and their relatives were informed when the residents changed their GP.” We have highlighted that the organisation’s decision to change to the services of a contacted GP did not demonstrate an inclusive or individualised person centered approach. This was a view shared by other health professionals through comments received in response to previous CSCI professional surveys. We noted that the information submitted, as part of the AQAA was not entirely accurate and could be viewed as misleading. The home had male and female staff employed so that residents could have a choice about gender of staff to assist them. There was also a cross gender care policy, which was updated by the previous registered manager as we had requested. However we noted from records, rotas and discussions that in practical terms residents may not always have a choice of gender of staff because of the high staff turnover, staff sickness and use of agency staff. We looked at a sample of residents’ health care records and found these had not been maintained to be up to date. We saw some evidence that residents had access to a range of specialists and generally had regular health checks. We saw that residents had regular reviews of medication, annual health checks, eye tests, dental checks, hearing tests and chiropody. Residents were weighed regularly and there were records of screening checks for potential health complications such as breast and testicular cancer. There were completed priority health screening documents and action plans in place but these were not updated. The acting manager stated that there was no “admin time” available. She told us that some residents were receiving support from the Priority Health Intensive Support Team but the IST worker was off sick. We discussed the home’s inconsistent recording of episodes of residents’ challenging behaviour, accidents and events, which would hinder the process of assessments with members of the IST. A resident had recently died at the home, after a short period of illness. We asked how this had affected the other residents, as they had lived together as a group for a long time. The Acting manager and supervisor told us that five of the residents seemed unaffected. However one person was showing signs of being badly affected, asking lots of questions, needing reassurance, with changes to his behaviour. He did not want to go out as usual. When we spoke with him he told us he was “sad and down”. We were told that support was being sought for him from the Psychology team, which was positive. We looked at the staffing rotas, care records and spoke to staff and we could not find evidence of extra resources or efforts to provide for end of life care for the deceased resident or the person who was grieving. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 23 At the random inspection on 2 April 2008 we had discussed the regulation 37 notification with the supervisor, sent to the CSCI on 5 March 08 relating to the medication error, which occurred on 23 February 2008. The supervisor acknowledged that there was not sufficient information recorded, and gave additional information. This related to the senior member of staff who had made the medication error he explained that they immediately contacted him and the GP and Pharmacy were contacted. The supervisor told us that the senior had no explanation as to why the error was made other than the person was the first resident up and the new BOOTS system placed resident’s medication in alphabetical order. The senior had no explanation why the procedure was not followed for checking the medication before administering it. We were seriously concerned because this was the second medication error where the same resident has been given the wrong medication. The acting manager told us, at that time, all staff had been working extra shifts to provide cover at the home and had not been taking their regular two days off each week and that she had tried to remedy this, ensuring that people could take their allotted time off. Although we had been told advice was sought from the Pharmacy and GP this advice was not recorded. We had been particularly concerned to note that the resident’s records indicated an allergy to Chlorpromazine, one of the medicines administered in error. We left an immediate requirement for the acting manager to clarify with GP and BOOTS pharmacy the contact and advice given to the home. We also strongly recommended that the acting manager undertook a documented supervision session to ensure that senior staff felt confident with the administration of medication. We asked the acting manager to show us evidence of her actions to ensure residents receive the correct medication and that staff have been supported and monitored. She acknowledged to us that she had not taken action as required and recommended at the inspection visit in April 2008. The acting manager told us that all members of staff who administer medication had received accredited medication training and staff had also received training to use the MDS system, which was implemented by BOOTS Pharmacy. We saw evidence of certificates for the supervisor and 2 senior carers, together with evidence of refresher training 31/1/08. We noted that the manager had introduced photographs of each resident on the medication system, which reduced the risk of giving residents the incorrect medication. We saw that the home had a copy of the organisation’s medicated policy dated 12 February 2008 and the manager had written an accompanying procedure relating to the practice at the home. We were shown a copy of the contract with the Pharmacy Provider, BOOTS and a copy of the most recent pharmacy audit dated 20/5/08, with the only outstanding recommendation for the trolley to be secured to the wall when not in use. We have examined Medication Administration (MAR) sheets, which were generally well completed. However there were a small number of gaps with no The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 24 appropriate signatures or codes for non-administration. We also noted handwritten entries without a signature and witness signature. We noted during our assessment of the home’s management of residents’ medication that there appeared to be a discrepancy relating to the administration of Soluble Paracetamol for a resident on the morning of 5 August 2008. The MAR sheets appeared to indicate that two doses of Paracetamol 500mgs x 2 soluble tablets given. We asked the acting manager to clarify the dosage given and to notify us of the outcome. We attempted to audit the total of tablets administered and those remaining. We discovered that the staff had contacted the GP to visit in relation to this person’s severe abdominal pain the acting manager told us they had accepted a verbal instruction from the GP to administer Paracetamol, although it was not already prescribed. They told us they had used another resident’s Paracetamol purchased for her as a homely remedy, dated as opened 25/10/08. There was no record that the GP had ratified the use of this homely remedy for the resident. We strongly recommended that the home do not accept verbal prescriptions over the telephone and where the residents require medical attention this be sought through a visit in person, alternatively if the situation is urgent, such as severe pain and a GP is unable to visit quickly, hospital attention should be sought. We noted that carried forward balances of medication held in stock were not recorded on the MAR sheets, which meant that medication audits were difficult to carry out. We saw that medication was generally appropriately stored and keys held securely with a documented hand over at each shift change. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 25 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is poor Residents cannot have confidence their concerns or complaints will be listened to or investigated and the recruitment and management practices do not protect residents from harm or abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a copy of the organisation’s complaints procedure and there was a pictorial format of complaints procedure for the residents who could not understand written information. The home’s AQAA completed by the acting manager stated that there had been 3 complaints in the past 12 months, investigated within the 28-day timescale. We were not able to see the complaints log and so were unable to establish the nature of the complaints or the outcomes. The home was issued with a requirement a the last key inspection, for arrangements to be made to ensure that all staff have a clear understanding of adult protection and whistle blowing procedures and fully adhere to these. This was to ensure that residents were not at risk of harm or abuse. At the random inspection in April 2008 the acting manager told us she was keen to promote and support staff training, including safeguarding training. However at that time due to staff shortages, recruitment of new staff, and heavy dependence on agency staff who may not have received appropriate training to safeguard vulnerable adults, there was insufficient evidence and no confidence that all staff had received appropriate training and had sufficient The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 26 understanding and awareness to adhere to policies and procedures. The AQAA completed by the acting manager in May 2008, stating what had improved, “Acknowledgement of staff to say they have read and understood the policies and they sign to confirm this.” We asked to see documentary evidence of staff signatures. The acting manager acknowledged that this had not been done. We discussed with her the importance of being accurate with information given as evidence to the CSCI. The acting manager told us that the home was now fully staffed with a staff team of 13 people, however we noted from the AQAA that 12 staff, 6 full time, 6 part time had left the home’s employ in the past 12 months, which meant that staff who may have received safeguarding training were no longer working at the home and several new staff have yet to receive training. At the random inspection in April 2008 the acting manager told us that 2 staff had been dismissed as a result of adult protection investigations. At this inspection we looked at the recruitment files of 4 new staff. There were references which were not authenticated and one person had been allowed to commence employment at this home after her employment had been terminated from another home in the company, a gap in employment and without new employment references, POVA, or CRB disclosure. At the random inspection we raised the concern that there was no designated person to be responsible for the home from 2100 – 0700 hours, which were vulnerable high risk times. The home had received an allegation relating to the conduct of an agency worker, which potentially placed the residents at risk. This was investigated with other agencies and though there was insufficient evidence to substantiate the allegation, it highlighted areas where additional safeguards were needed. Following the random inspection in April 2008 we issued the registered person with an immediate requirement to ensure that there was a designated suitably qualified, competent, and experienced person, to be responsible for the home at all times and especially from 2100 - 0700 hours to promote and make proper provision for the health and welfare of the residents. At this key inspection we examined the rotas from 2 May 2008 to the date of this inspection visit and saw evidence that the acting manager had placed the inexperienced, untrained member of staff, without appropriate recruitment clearances with other recently recruited, inexperienced, untrained members of staff and agency workers, without adequate recruitment and induction documentation, on “sleeping in duties” for a total of19 shifts in breach of the Regulation. None of the staff rotas we examined from 2 April 2008 to 5 August 2008 identified a designated person to be responsible for the home from 21:00 – 07:00 hours. We explained the seriousness of this lack of compliance with the requirement, which had been issued to safeguard residents and staff at the home. We were told that the organisation now used an agency to supply care workers, to cover when there were staffing shortages. The acting manager told The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 27 us that the home holds information on each of the agency worker. However the information seen at this inspection was not as comprehensive as information held about agency workers seen at the Random Inspection 2 April 2008, which we indicated was not adequate at that time. We examined accident records and noted the number of accidents, which had occurred during the evening and night hours. We also noted the high number of incidents where residents have ‘hit’ each other or members of staff. The acting manager acknowledged that she had not undertaken any analysis, evaluation or put any risk assessments or risk management strategies in place. She did not recognise that safeguarding referrals must be made where there is physical aggression between residents and there were no Regulation 37 notifications to the CSCI of these incidents. A resident approached us, as we were about to leave the home at 20:15 hours. He told us that another resident, in the dining room, had slapped him on the hand the previous day. We established staff had not logged this incident. He told us there were no staff in the dinning room at the time. He also told us he was “frightened and locked himself in his bedroom at night”. He told us he wanted to leave the home. With the resident’s consent and knowledge we have made the acting manager aware of this incident and asked her to make a referral to the Dudley Community Learning Disability Team and Safeguarding Co-ordinator. She asked for the contact details and we referred her to the Safeguard & Protect Procedural guidance and contact numbers. We have made the acting manager and registered person aware that safeguarding referrals have been made to Dudley Directorate of Adult Care and Housing Services (DACHS) regarding these individuals in accordance with the Safeguard and Protect procedure. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 28 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Quality in this outcome area is adequate This is a homely comfortable place for residents to live with some refurbishment and redecoration, which has improved the standard of some of the décor, fixtures and fittings. The premises are generally clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During our tour of the premises some of the residents wanted to show us their bedrooms. The residents’ bedrooms were generally fresh, clean and were decorated and furnished to suit each person’s individual tastes and preferences. The rooms contained residents’ personal belongings and were homely. One resident had his own kettle to make drinks, though he told us he needed his mug to be returned. There were a number of areas, which needed attention in residents’ bedrooms. Examples were; first floor bedrooms with wardrobes, which were not secured to the wall, a full length window with a broken window restrictor, a compromised double glazed window unit, worn and stained carpets. We also issued an immediate requirement for action to be taken in relation to the carpet in the ground floor bedroom, which was very The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 29 faded and worn, was frayed along the join into the window recess, presenting a tripping hazard for the resident in that room. Although the manager told us that residents do not require the assistance of any aids or adaptations, we noted one resident had a number of falls and we were told she had fallen downstairs “sometime last year”. The risks had not been assessed for this person. We strongly recommended that the advice of a qualified occupation therapist be sought in relation to the environment for residents with increasing physical disabilities. At the key inspection in June 2007 the operations manager told us there were plans to carry out a programme of redecoration in the near future. Although we saw some evidence of a planned redecoration and refurbishment programme, this seemed to have come to a halt and there are some areas of the home that were still looking tired, worn and in need of attention. We noted that the ceiling in the small communal toilet on the ground floor needed some attention and the extractor fan was very noisy. In the hallway, stairs and landing there were missing light bulbs and the handrail was very sticky, posing potential hazards for residents and staff. The energy efficiency light bulbs were not as bright as conventional lights and we recommended that the Lux rating be established to ensure the lighting levels did not pose additional risks for residents’ safety. The main lounge had been redecorated in calming colours, with a new carpet provided. However the leather sofa was torn on the seat and light bulbs were missing from the ceiling light fitting. We were told that the home is changing all the light bulbs into energy efficiency bulbs. We were also told that there were plans to remove the unused gas fire. The conservatory had been completely replaced, as the previous structure was considered to be unsafe. We saw that the accessible windows in the new conservatory were unlocked and had no window restrictors fitted. There was a considerable drop to ground level outside. The manager told us staff monitored residents using the conservatory but acknowledged that she had not put any written risk assessments in place. Furthermore we observed a resident walking round and round in the conservatory unsupervised, whilst staff were engaged with other tasks. A number of previous recommendations had not been actioned. The acting manager acknowledged the lack of action, citing the lack of time and dedicated maintenance resources. Examples were in the communal toilet on the first floor a wardrobe had been installed as storage; this had not been either secured or removed as recommended at the key inspection in June 2007. We noted during our tour of the premises that the wooden radiator covers in the dinning room had large (approximately 4”) gaps at the top, where we were able to touch the excessively hot radiators. There were several other radiators The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 30 around the home with similar gaps, giving access to any resident who wished to touch the radiators. The radiators had no accessible thermostatic control to lower the surface temperature. These posed significant risks to residents who may not move away before being burned. Additionally a resident called us to see how she was opening a cupboard in the dining room, where the gas, electricity meters and exposed cables were located. She was placing paper in the cupboard. The laundry, on the first floor was small but was clean and tidy. There was a locked cupboard for substances hazardous to health and we recommended that appropriate up to date information should be displayed for staff guidance. There was a supply of dissolver bags for washing soiled or infected laundry and laundry bags for transporting dirty laundry through the premises. We spoke to a member of staff who indicated that sometimes staff manually sluice soiled linen before it is put in the washing machine, we have strongly recommended that this practice is avoided and the laundry procedure be updated. There was a supply of liquid soap and paper towels. There had been no action to implement a programme for a daily cleaning programme, especially for mops used around the home, which were not washed on a daily basis at thermal temperatures. There was no evidence that advice had been sought from the infection control nurse as recommended at the inspection in June 2007. The kitchen was clean and tidy, however we were told there was no date for the planned refurbishment, which was long overdue. We found out of date prepacked cold meat in fridge dated the 25/07/08. We were told that a member of staff had taken it out of freezer the day before, however there was no label to evidence this. We also noted that the temperature reading for the fridge was high. The acting manager informed us that the fridge was going to be changed. We noted pickle in a cupboard, which should have been refrigerated when opened; staff discarded this item during the inspection visit. We noted that staff were aware of food safety and used colour coded chopping boards for food preparation. We also noted a good, varied range of food and a mixed assortment of fresh fruit available. The dining Area had a white board representing menus, with pictures cut out from magazines. Unfortunately it was only completed with some days of the week and had no pictures of the current day’s menus. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 31 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34, 35 Quality in this outcome area is poor. There is a high turnover of staff and a lack of management of the skill mixes means that residents cannot rely on consistent support from a well trained, qualified and experienced staff group. Staffing shortages have a negative impact upon support available for residents to have individual choices and a fulfilling lifestyle. Recruitment and selection practices do not offer protection to residents. Induction programmes are not adequate to meet the specialized needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ay the previous key inspection in June 2008 a requirement was issued to ensure that there are sufficient numbers of staff working on shift to meet all of the needs of residents particularly with regard to undertaking individual as well as group outings into the community. As we have highlighted at the Lifestyle section of this report staffing shortages had severely curtailed opportunities for group or individual activities provided by this service. This meant that the requirement had not been met. At this key unannounced inspection we examined the working rotas, accident records and ABC Incident Records. We identified a number of shifts the staff The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 32 rotas from the week ending 20 July 2008 where the staffing levels had decreased, on a number of occasions, to only two staff on duty during the wakeful day. The acting manager and staff told us that since the death of a resident on 16 July 2008 they had been instructed two staff were adequate meet the needs of the 6 remaining residents. We saw evidence that the six residents have individual and very diverse dependency levels, care and support needs. In addition there was considerable evidence that the majority of residents were exhibiting challenging behaviours towards each other and members of staff. The acting manager told us she was unable to take allocated managerial hours and was almost always one of the carers on day shifts, undertaking ‘hands on’ tasks supporting residents. We noted that the acting manager, senior care staff and support workers undertake all catering, laundry and all cleaning duties since the domestic assistant left the home. As we have previously highlighted these ancillary duties deplete the number of care and support hours available for residents. These findings provided further evidence of the breach of the previous requirement. At the Random inspection 2 April 2008 we highlighted the concern about the lack of a designated person to be responsible for the home from 2100 – 0700 hours. We noted from the rotas recently recruited staff, with limited or no care experience had worked shifts as “sleep in” staff. They were rota’d with agency workers or other staff with limited or no care experience or qualifications working on the wakeful night shifts. At the random inspection we issued a requirement to be actioned with immediate effect: to ensure that there was a designated suitably qualified, competent, and experienced person, to be responsible for the home at all times and especially from 2100 – 0700 hours to promote and make proper provision for the health and welfare of the residents. None of the staff rotas we examined from 2 April 2008 to 5 August 2008 identified a designated person to be responsible for the home from 21:00 – 07:00 hours. This meant that the home had breached the Care Homes Regulation, which may result in the CSCI taking further enforcement action to obtain compliance to safeguard vulnerable residents. As indicated at the Complaints & Protection section of this report we were told that the home uses an agency to supply care workers to cover staff shortages. At the random inspection 2 April 2008 we issued an immediate requirement for the registered person to ensure that fuller details of agency staff are held at the home including identification, photograph, full address, all training undertaken, and dates of the training. We examined the ‘handwritten’ record of one agency worker, which gave the name, no date of birth, no full address, “CRB form to be sent on 2-01-2008” but no date of issue and there was no career history, or employment history, and no indication of references, other than “2 satisfactory references”. There was a list of training, but not the dates of training. There was a brief induction to the home dated 31/12/07, which was the same date given for the date recorded as commencing work at the home. There was an employee risk assessment form, which was not fully completed, dated 12/6/08. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 33 There were numerous entries on staffing rotas from 14 April 2008 to 11 July 2008, where agency staff had been used to cover shifts. We noted some entries did not give the name of the agency worker. The staff rota for 07 - 20 July 2008 indicates “agency” as wakeful carer for 07/07/08 and 08/07/08 but no names entered. We asked the acting manager for the name(s) of the agency workers to check their records held at the home. The acting manager told us that she could not remember the names of the agency staff used and she would need to check the communication book. She could not locate the communication book. We asked her who had booked the agency cover and she told us that she had booked the workers. We were unable to verify who the agency staff were, whether the home had obtained any information or whether they had received any induction or had any knowledge of the resident’s needs. Other dates of unnamed agency workers on staffing rotas were: 10, 11, 22, 30, 31 May 2008, 12, 14, 15 June and 3,4,5 July 2008. There were numerous occasions recorded on the staffing rotas where agency workers were on duty for the “sleep in” as support for recently recruited support workers who had no formal care qualifications and little or no experience of working with people who have learning disabilities and complex needs. From the evidence we have seen the service we informed the acting manager and wrote to the registered person with our serious concerns that the failure in compliance with Care Homes Regulations had again placed residents at risk. The information contained in the home’s AQAA indicated that 12 staff had left the home’s employ in the past 12 months, 6 full time staff and 6 part time staff. The acting manager confirmed that this high level of staff turnover was accurate. From the information given we established that there were only 3 staff including the acting manager who had worked at the home for 12 months or more, which meant that residents were not receiving support and care with continuity from people who knew them well. We looked at the recruitment files for 4 new members support workers. One file indicated that there had been difficulty in obtaining references; another had a reference from a previous employment of very short duration, without reasons for leaving. The organisation had not always sought authentification of references from previous employers, for example requiring a company stamp, headed paper, or following up with a documented telephone check. We examined the personnel file for a new member of staff, who had previously worked at another home in the organisation, from August 2007 – January 2008. The application for a post of support worker at The Dell was dated 03/04/08. There was no new recruitment information on the personnel file, all recruitment information, apart from the application form, related to the previous employment at the previous home. There were no new references, no new POVA or CRB, as far as the acting manager was aware. The POVA first The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 34 clearance was dated 14 September 2007 and the CRB on file was dated 4 October 2007. There was a letter on file terminating her employment at the previous home, citing an unsatisfactory probation period, due to levels of sickness absence, as of 14/01/08. The member of staff commenced work at The Dell on 28/4/08 and had also been absent through sickness whilst employed at The Dell. We discussed with the acting manager her actions; she had placed this inexperienced, untrained member of staff, without appropriate recruitment clearances with other recently recruited, inexperienced, untrained members of staff and agency workers, without adequate recruitment and induction documentation, on “sleeping in duties” for a total of 19 shifts from 2 May 2008 to the date of this key inspection visit. This did not demonstrate compliance with the immediate requirement from the random inspection 2 April 2008, issued to safeguard the health, well-being and safety of residents at the home. We have written to the registered person to register our serious concerns and re-issued immediate requirements to take action to safeguard the residents living at this home. The acting manager told us that she was not involved in the recruitment of new staff. This was very disappointing given our strong recommendation issued at the Random Inspection 2 April 2008, that the acting manager should be involved in recruitment of all new staff and that processes should also be put in place to include the involvement of residents. We had discussed our recommendation for improved recruitment practice with the registered person (Responsible Individual) and the operations managers at an improvement strategy meeting with the CSCI on 8 April 2008.The acting manager stated that she does not meet staff and they do not visit The Dell to meet her or the residents prior to their allocation to work at the home. She stated that the operations manager undertook staff recruitment, with interviews held at the head office and all decisions made by the operations manager. The acting manager explanation to us was that she has been told by the organisation that she was now fully staffed, however there were only three senior care workers employed to cover all shifts at the home and one person had been on extended sick leave and was on an extended holiday overseas at the time of this inspection visit. There was no evidence that the CSCI had been notified of staff shortages, contingency measures or that the staff were being used on a POVA first basis. We looked a sample of staff training records and the training matrix, which included the names of some staff who were no longer at the home and the name of the newest recruit was not recorded. We noted that 5 staff had not completed the common induction standards, only 2 staff had the LDAF (Learning Disability Framework Award) and 3 staff had an NVQ 2 (or above) care qualification, including the 2 staff with the LDAF award. The previous recommendations to provide staff training for various topics, including epilepsy and the Mental Capacity Act had not been met. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 35 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is poor. Management practices within this home are not effective and place residents at risk of harm. Quality monitoring systems are unproductive and do not ensure the home accurately monitors its performance. This means the quality of service residents receive is inconsistent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous registered manager for The Dell retired in June 2007 and the acting manager was appointed in September 2007. At the random inspection on 2 April 2008 we held discussions with the acting manager about how many dedicated managerial hours she had each week. She told us that she had to do the majority of her hours as care shifts and even when she planned “admin hours” on the staff rota she usually had to give assistance with the residents. At the random inspection we discussed with the acting manager the fact that The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 36 no application had been received from her to be registered as a fit person to manage The Dell. At that time she stated that she did not feel that she had sufficient time to implement improvements to the home, such as a robust quality assurance system. During discussions at this key inspection she acknowledged that she had not yet submitted an application to CSCI to be registered as manager for the Dell. We noted from discussions with the acting manager, senior staff and examination of rotas that there were sufficient dedicated managerial hours allocated. At the random inspection we strongly recommended that the manager had sufficient managerial hours to plan, set goals, monitor, review and improve the quality of the service provided for residents living at The Dell. The acting manager had told us at the random inspection that she was taking personal responsibility for improving the residents care plans, risk assessments and encouraging staff to improve record-keeping. We were deeply concerned that not only has little or no progress been made to meet Requirements and Recommendations issued at previous inspections but we noted sharp deteriorations in some crucial aspects of the service provided to support and care for residents living at this home. We examined accident records and noted the number of accidents, which had occurred during the evening and night hours. We also noted the high number of incidents where residents have ‘hit’ each other or members of staff. The acting manager acknowledged that she had not undertaken any analysis, evaluation or put any risk assessments or risk management strategies in place. She did not recognise that safeguarding referrals must be made where there was physical aggression between residents and there were no Regulation 37 notifications to the CSCI of these incidents. We saw ABC records, which indicated that there were injuries and repeated falls. These were not documented in accident records and there was no evidence that health professional advice had been sought. The acting manager acknowledged that she had not implemented appropriate monitoring systems, in particular regular accident and incident analysis and evaluation, referenced to residents’ daily progress records used at shift handovers. There was very limited evidence of a robust quality assurance system. There were records of Regulation 26 reports; the last dated 26 May 2008. The acting manger stated that other visits had taken place since that date and reports were on the computer. However we have not seen copies of any further reports to the date of writing this report. We noted that the reports relating to regulation 26 visits, monitoring the conduct of the home had not been effective in monitoring compliance with the Requirement issued at previous inspection visits and identifying breaches of regulations. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 37 We were told that staff meetings happen once a month, and saw evidence of meetings on 23/01/08, 14/04/08, 04/06/08, and 13/06/08. We saw some evidence of residents meetings, dated 28/01/08, 13/04/08, 04/05/08, and 13/07/08. We also saw copies of the acting manager’s supervision records dated 01/10/07, 13/11/07, 05/02/08, and 04/07/08. Though these show some actions there was no evidence that they had been monitored or evaluated for successful outcomes. We had sent CSCI surveys for residents, staff and health professionals, with stamped addressed envelopes, to the home to be distributed and returned to the CSCI Birmingham Office but had not received any responses. We discussed the lack of response with the acting manager, who told us that they had only received surveys for residents, which had been completed and posted to the CSCI office. We did not see evidence of the home’s own surveys or any collated results. We looked at a random sample of health and safety, fire safety and service maintenance records, and mandatory staff training records. There were some records, which were satisfactory but there were also omissions. Some examples were: Although the central training matrix showed that 13 staff had received fire training since June 2008, the most recent recruit was not included on the record and there were no records to show that agency workers had received fire awareness or a fire drill relating to The Dell. There was no evidence to show that agency workers were formally made of the residents’ needs or assistance required in an emergency, such as fire. We noted that 3 staff had not received health & safety training, there was no record of first aid training for 3 staff and the acting manager, 5 staff and the acting manager had no recorded date for moving & handling training, 3 staff and the acting manager had no recorded date for food hygiene training, even though they prepared, cooked and served meals, 3 staff had no infection control training, there was no evidence of medication training for the acting manager and 7 support workers, even though they were involved in checking medication on occasions, 7 staff including the acting manager had no record of safeguarding training and records showed that 3 of 5 staff had received training in 2006. Although we were told the acting manager, supervisor and 2 senior carers had received risk assessment training there was no documentary evidence produced at the inspection visit. During the inspection we examined the documentation for the minibus and identified that though an MOT had been obtained in March 2008, the Insurance documentation had expired on 31 March 2008. Staff at the home were unable to locate up to date insurance documentation. The invoice for payment was dated 15 January 2008 and cover note was dated 11 July 2008, these documents were faxed from the head office. We were told that there were no senior managers available who could be contacted for clarification or for support for this home. Following the inspection visit the organisation provided documentary evidence of up to date insurance cover. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 38 As already mentioned earlier in the earlier sections of this report we received the homes Annual Quality Assurance Assessment report. We found the information in this to be inaccurate and misleading. As we have highlighted throughout this report record keeping was poor and we expressed our serious concerns about the number of records, which were not properly completed. The records are to safeguard residents and demonstrate that the home can meet their needs to maintain their health and well being. We have made the registered provider aware that in view of these serious concerns the Commission for Social Care will carefully consider further enforcement actions, which may be taken to safeguard the residents living at this home. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 39 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 2 26 1 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 1 34 1 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 1 2 LIFESTYLES Standard No Score 11 2 12 1 13 3 14 1 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 1 1 X 1 X 1 1 X The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 40 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 YA6 Regulation 13(1) Requirement The registered person must take action to ensure that the all health care risk assessments and care plans reflect all changes to residents’ health and needs. This is to ensure care for residents’ health and well being is properly provided at all times The home must be able to show how they have involved the people who use the service in the planning of their end of life care. This is to make proper provision for the health and welfare of residents. The registered person must ensure that residents are reimbursed for the costs of staff accompanying them on the planned holiday and that the practice of residents contributing to any costs of meals, refreshments, travel or accommodation whilst on outings, holidays ceases with immediate effect. The registered persons must ensure that action is taken to DS0000069594.V369529.R01.S.doc Timescale for action 01/10/08 2. YA6 12(3) 01/10/08 3. YA7 13(6) 06/08/08 4. YA9 13(4) 01/10/08 The Dell Version 5.2 Page 41 minimise and review all aspects of risk for each resident, with documented, up to date risk assessments and risk management strategies in place. This is to ensure that the health and welfare of people living in the service are safeguarded. 5. YA20 13(2) 1) The registered person must ensure that full records relating to any medication error are maintained, including contact with GP any advice given and actions taken. Previous Timescale of 14/04/08 Not Met 2) The registered person must ensure that action is taken to clarify with the GP and BOOTS pharmacy the contact and advice given to the home to minimise the risk to the resident following the medication error on 23/2/08. Previous Timescale of 14/04/08 Not Met 6. YA20 13(2) The acting manager must clarify the dosage of Paracetamol given to the resident on the morning 5/8/08 and notify the CSCI of the outcome 06/08/08 05/08/08 7. YA20 13(2) 1) Medication records charts 01/09/08 must document the correct amount of medication administered to a service user or an appropriate code recorded with a reason if medication is not administered to a service user. This is to ensure that the health and welfare of service users are safeguarded. The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 42 2) Service users care plans must be kept up to date with medication changes in order to ensure that the health and welfare of service users are safeguarded. 3) All medication that is prescribed PRN (as required) must have a care plan that clearly shows the circumstances in which the medication is administered; this must be kept under review. Arrangements must be made to 05/08/08 ensure that all staff have a clear understanding of adult protection and whistle blowing procedures and fully adhere to these. This is to ensure that residents are not at risk of harm or abuse. Timescale of 01/06/07 Not Met at the Random Inspection 02/04/08 and Not Met at this Inspection 9. YA23 13(6) The registered person is required to take action to ensure that all incidents, accidents or events, which adversely affect the well being or safety of residents are notified to the CSCI in compliance with Regulation 37 and referred to the Lead Agency in compliance with the ‘Safeguard & Protect procedure’, without delay. This is to ensure that residents are not at risk of harm or abuse. To ensure that there are sufficient numbers of staff working on shift to meet all of the needs of residents particularly with regard to undertaking individual as well as group outings into the DS0000069594.V369529.R01.S.doc 8. YA23 13(6) 05/08/08 10. YA33 12(1)(a) 05/08/08 The Dell Version 5.2 Page 43 community. This is to make proper provision for the health and welfare of residents. (Previous Timescale of 01/08/07 and Not Met at the Random Inspection 02/04/08 and Not Met at this Inspection 11. YA33 12(1) The Registered person must ensure that there is a designated suitably qualified, competent, and experienced person, to be responsible for the home at all times and especially from 2100 0700 hours to promote and make proper provision for the health and welfare of the residents. Previous Timescale of 09/04/08 Not Met 12 YA33 12(1)(a) The registered person is required to submit a documented assessment of residents’ occupancy and dependency levels, staffing levels and a copy of 4 weeks staffing rotas, including ancillary staff and risk assessments for all staff employed on a POVA first basis, to be received at the CSCI Office, Birmingham by 0900 hours on Friday 8 August 2008. The registered person must ensure that a Regulation 37 notification is submitted for any occasions where there are staffing shortfalls, with contingency measures clearly identified, with immediate effect. This is to ensure that residents are not at risk of harm or abuse. DS0000069594.V369529.R01.S.doc 05/08/08 08/08/08 13. YA33 12(1)(a) 05/08/08 The Dell Version 5.2 Page 44 14. YA34 19(1) Schedules 2&4 The registered person must ensure that fuller details of agency staff are held at the home including identification, photograph, full address, all training undertaken, and dates of the training. This is to ensure that residents are not at risk of harm or abuse. Previous Timescale of 14/04/08 Not Met 05/08/08 15. YA34 19(1) Schedules 2&4 The registered person is required to ensure all documentation required by the Care Homes Regulations 19(1) schedules 2 and 4 is available and up to date for all staff working at the care home. This is to ensure that residents are not at risk of harm or abuse. All new staff must have an induction that meets the Skills for Care guidance. Records of induction must be kept. All new workers must be supported and supervised throughout their induction period by a suitably qualified person. 08/08/08 16. YA35 18 (2) 01/10/08 17. YA37 9(1) The registered person must ensure that the acting manager submits an application to the CSCI for registration as a ‘fit person to manage a Care Home without any further delay 1) The registered person is required to ensure with immediate effect that documented risk assessments and control measures are DS0000069594.V369529.R01.S.doc 01/10/08 18. YA42 13(4)(c) 05/08/08 The Dell Version 5.2 Page 45 implemented to minimise the risks from: • Excessively hot radiators, throughout the home, which are accessible to residents, to safeguard them from risks of burns. - The unlocked cupboard in the dining room, where the gas, electric and cables are located, The badly frayed carpet in the ground floor bedroom, to reduce the tripping hazard. • • 2) The registered person is required to take action to rectify the radiator covers, with excessive gaps, to ensure the cupboard housing utility meters and cables is secured and repair or replace the carpet in the ground floor bedroom to safeguard residents from risks of harm. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations That the home’s statement of purpose and service user guide is regularly reviewed and updated to provide people with accurate information, including details of fees. It is suggested that details of additional charges with regard to some items of toiletries are made more explicit in the service user guide and residents’ contracts. Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 46 2. YA1 3. 4. YA6 YA6 Service users should be involved in the planning and reviewing of their own care It is recommended keeping the care plans simple and person centred, writing them in the first person wherever possible and using easy words and pictures. Not Met at this Key Inspection 5. YA7 To consider pursuing referrals to speech and language therapists for assistance in developing communication passports. Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection 6. YA9 To review, update and expand written risk assessments to ensure that any unnecessary risks to the health and safety of residents are identified and so far as possible eliminated for example with regard to the use of wheelchairs. Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection 7. YA12 To ensure that staff more consistently and accurately complete activity records. Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection 8. YA16 To review ‘consent’ forms for residents’ rights, which have been signed on behalf of residents by their families. If residents are unable to give consent, then staff should consider making decisions based on their best interests as in compliance with the Mental Capacity Act 2005. Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection 9. YA17 It is suggested that meal preparation and cooking are included as an activity on residents’ activity menus to see whether their interest or participation in this task can be encouraged. Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 47 10. 11. YA17 YA17 Residents would benefit from a planned menu that includes their own individual likes and dislikes That advice from community nurse specialists and community dieticians be sought for all residents assessed to be nutritionally at risk, with records of support and advice offered and that a record be maintained of staff training in relation to nutrition It is strongly recommended that the acting manager uses documented supervision session to ensure that senior staff feel confident with the administration of medication. Not Met at this Key Inspection 12. YA20 13. YA20 It is strongly recommended that the staff do not accept verbal prescriptions over the telephone and where the residents require medical attention this be sought through a visit in person That there are records to show that the GP has ratified the use of any homely remedies used for each resident. That carried forward balances of stocks of medication are recorded on the MAR sheets, for accurate auditing That receipt of all medication is recorded and signed for on the MAR sheets That all hand written entries on MAR sheets are signed and witnessed by staff who are trained / competent with medication To obtain a copy of the ‘complaints leaflet’ referred to in the complaints procedure and which is to be sent to any complainants. Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection 14. 15. 16. 17. YA20 YA20 YA20 YA20 18. YA22 19. YA23 That behaviour care plans be expanded with fuller information to guide staff to understand behaviour triggers for individual residents and how to manage behaviour that challenges, such as agitation, wandering etc. That action is taken to involve appropriate advocacy for decision making for residents lacking capacity, in relation to The Mental Capacity Act 2005. DS0000069594.V369529.R01.S.doc Version 5.2 Page 48 20. YA23 The Dell 21. YA23 Staff should be made aware of the homes abuse policies and Dudley Council’s Adult Protection procedures. It is advised that staff sign and date when they have read these documents. To progress with an audit of the premises from which a written programme of refurbishment and redecoration must be produced together with timescales for completion. A copy must be forwarded to the Commission for Social Care Inspection. To ensure that the wardrobe in the communal toilet is secured to the wall. Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection 22. YA24 23. YA24 To implement a maintenance and repair programme to rectify the following: • • • • • Rectify all wardrobes, which were not secured to the wall Rectify the a broken window restrictor on a first floor full length window Rectify the compromised double glazed window unit in a residents bedroom Replace all worn and stained carpets Renovate the ceiling in the small communal toilet on the ground floor needing attention and rectify the very noisy extractor fan Replace all missing light bulbs Rectify the very sticky handrail on the stairs The Lux rating be established to ensure the lighting levels, provided by energy efficiency light bulbs do not pose additional risks for residents’ safety Repair or replace the leather sofa with the torn seat • • • • (This is not an exhaustive list) The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 49 24. YA29 That advice is sought from the occupational therapy team for assistance with providing appropriate care and facilities for the any person with significant physical and / or sensory impairment. To ensure that the carpet in the communal lounge is cleaned and that a regular programme of cleaning is maintained. To ensure that mops are dried inverted and mop heads are washed daily at thermal temperatures (or to seek advice from the infection control nurse about current practice). Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection 25. YA30 26. YA30 It is recommended that the home obtain a copy of the Department of Health guidance Infection control in Care Homes published June 2006 and that all staff are made aware of this guidance To consider providing staff with specialist training in the Mental Capacity Act 2005 and person centred planning. To consider providing refresher training to staff in managing challenging behaviour. Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection 27. YA32 28. YA33 That new members of staff undertaking induction, before commencing work as a care worker, should not be used as a third member of staff on shift Not Met at this Key Inspection It is strongly recommended that the acting manager is involved in recruitment of all new staff and that processes are also put in place to include the involvement of residents. Not Met at this Key Inspection 29. YA34 30. YA35 To ensure that staff receive full and structured induction training suitable for the work they are to perform, and in order to meet the specialist needs of the residents. A written record must be maintained at the care home. Not Met at the Random Inspection 02/04/08 The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 50 To ensure that all staff receive equal opportunities including disability equality training. To provide induction and foundation training for staff by an accredited learning disability awards framework (LDAF) provider. Not assessed at Random Inspection 02/04/08 Not Met at this Key Inspection 31. YA35 A thorough training needs assessment should be undertaken with a consequent training plan and an up to date training programme. It is strongly recommended that the manager have sufficient managerial hours to plan, set goals, monitor, review and improve the quality of the service provided for residents living at The Dell. Not Met at this Key Inspection 33. YA39 That the annual development plan reflects all aspects of the home and is diligently monitored. Not Met at this Key Inspection 34. YA39 There must be an effective assurance system in place that includes accurate quality monitoring systems, which meet all elements detailed in standard 33. The registered person must ensure that the information provided in the AQAA ‘s submitted to the CSCI is accurate and up to date, as this will be verified at inspection visits That Regulation 37 notifications be fully completed with all relevant information to demonstrate residents are safeguarded and risks are minimised. That the registered persons review the documented accident analysis to more clearly identify continued risks, trends and record remedial / control measures, which should also be reflected in each person’s care planning and risk management 32. YA37 35. YA39 36. YA41 37. YA42 The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 51 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Dell DS0000069594.V369529.R01.S.doc Version 5.2 Page 52 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!