Inspection on 14/10/08 for The Limes Blackheath

This inspection was carried out on 14th October 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 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Limes Blackheath 17/04/09

The Limes Blackheath 26/10/06

The Limes Blackheath 31/01/06

The Limes Blackheath 24/08/05

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 30/01/2009.

CARE HOME ADULTS 18-65 The Limes Blackheath 37 Avenue Road Blackheath West Midlands B65 0LP Lead Inspector Sally Seel Unannounced Inspection 14 October 2008 & 23 October 2008 07:30 The Limes Blackheath DS0000063539.V368013.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 Limes Blackheath DS0000063539.V368013.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 Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Blackheath Address 37 Avenue Road Blackheath West Midlands B65 0LP 0121 559 3935 0121 561 1333 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) Mr Mohammed Iftikhar Ali Debbie Bennett-Hopper Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1) of places The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2006 Brief Description of the Service: The Limes is registered to make provision for a maximum of eight people learning disability. The home is situated within easy travelling distance of Blackheath town centre and close to public transport systems. The home has its own transport. This is used for holidays, group outings and to take service users to appointment, where applicable. Service user accommodation is provided over two floors. There are eight single bedrooms, four of which have en-suite facilities. The communal facilities on the ground floor consist of a lounge/dining area, conservatory and kitchen. Toilets and bathing facilities are available on both floors. There is a garden to the rear of the building. The main entrance is at the front of the building and limited car parking facilities are available at the side of the property. There are additional charges for toiletries, hairdressing and transport. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Two inspectors undertook this fieldwork visit to the home, over nine and a half hours and the acting manager assisted us throughout. The registered proprietor was also present for some of the first day of our visit. The home did not know that we were visiting on that day. There were six people living at the home on the day of the visit. Information was gathered from speaking to and observing people who lived at the home. Two people were “case tracked” and this involves discovering their experiences of living at the home by meeting or observing them, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. We partially case tracked a third person. Case tracking helps us to understand the experiences of people who use the service. Staff files, training records and health and safety files were also reviewed. The atmosphere within the home is inviting and warm and we would like to thank everyone for his or her assistance and co-operation. What the service does well: Efforts are made to ensure that people are supported and encouraged to maintain the relationships that are important to them. Individuals appeared to be supported well to maintain their personal hygiene wearing appropriate clothing that reflects their age, gender, personality and time of year. In the main interactions between the people living there and staff were friendly and relaxed. The people living there are supported to take part in a range of household activities and be as independent as possible. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plans must be implemented for all individual’s needs to ensure these are managed safely. Risk assessments must be implemented that inform choices and support people in their daily lives. Improvements to medication practices must happen to ensure greater protection to people. Detailed care plans, risk assessments and documentation for the monitoring and management of behaviours must be implemented in order that the staff have sufficient information to support individuals, whilst reducing where possible the risk of harm and/or injury. The home must ensure that they inform the relevant authorities about incidents that affect the health and wellbeing of people living in the home. The recording of accidents and incidents need to improve so that there are clear actions and outcomes recorded. This means that people are protected from harm and/or injury by the prevention of accidents occurring. Staffing levels must be maintained to the assessed needs of individuals living in the home. This will help meet their needs safely. The home must be able to demonstrate recruitment checks have been completed for anyone who works at the home. This will reduce the risk of harm to people. Staff must have completed mandatory training including refresher courses where appropriate. Also sufficient numbers of staff must have undertaken specialist training in order to meet individual needs. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 7 The home must develop quality assurance systems to ensure that services offered are reviewed, monitored and improvements made as necessary. This will ensure that people receive good outcomes. Health and safety checks must be maintained on a regular basis. This must happen to safeguard people. A list of requirements and recommendations are located at the back of this report if people wish to view. 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 Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People do not have up to date information as the statement of purpose has not been updated or reviewed since 2002. Information about the home is not in available formats that prospective individual’s can understand. Assessment processes do not ensure that individual needs are identified prior to moving into the home. EVIDENCE: There home have not had any new admissions since their last inspection and the local authority has suspended referring any prospective individuals to the home due to investigations being undertaken. In view of this outcomes for any new person coming to live in the home could not be assessed. The home does have a statement of purpose but this has not been updated since 2002 and the information supplied is outdated. For example, the previous registered manager and proprietors names are in the statement of purpose. The home and services offered refers to when the home was managed by the previous proprietors. Therefore people considering moving into the home would not know what the home provides and whether their needs could be met there. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 10 The statement of purpose is not in a format that the people who live at the home would be able to understand and/or people who could be considering moving into the home. For example, it is in written word as opposed of using colour pictures as aids to communication. We found one contract of residency in place at the home for one of people we case tracked out of the three care records we sampled. Therefore we could not wholly assess if peoples legal rights are being protected with regard to terms and conditions of residency. People told us, ‘Yes, I like living here’, ‘It is not too bad’. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There has been a lack of promoting person centred support and care based on individuals needs and capabilities. Care planning and risk management is not robust and individual’s needs are not identified, met and reviewed. EVIDENCE: We examined two peoples care records and partially looked at a third, talked to staff and indirectly observed practices and found that the care planning processes do not meet all individuals’ needs. At the homes last inspection on the 26 October 2006 a recommendation was made that all care plans should be reviewed and this was also recognised at the random inspection on the 12 June 2008. This is an example of the homes reluctance to complete specific pieces of work that can provide good outcomes for people. We found many examples of care planning that required further work so that people’s health The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 12 and wellbeing are not compromised. One person’s care records that we sampled held no information that staff could make reference to in relation to the changing health and care needs of an older person. In all three care records we could find no care plans that illustrated how individuals, family members or their representatives had been involved so that people are able to have their say on how their health and social care needs are met. Care records reflected that the acting care manager and senior carer were in the process of continuing to overhaul care plans with guidance being supplied from external professionals. However, the acting manager and senior carer have been in post for a couple of months. There is no evidence that would support members of staff who have been working at the home for a longer period of time has been involved in care planning. Also the acting manager and senior carer have been taking work home to complete and we advised that this is not protecting the rights of people and maintaining people’s confidentiality in line with the data protection act. We were assured that this practice would now stop. Behaviour management is not wholly risk assessed in respect of guidelines’ for the staff to follow when a person is at risk and this is identified. Although risk assessments are now being completed there were no specific guidelines for staff to follow when one individual is found lying on the floor. What we did find is that individual staff members were following different methods in how they would manage this type of situation. Some staff confirmed that they would try and encourage this person to get up immediately; other staff said they would leave this person for awhile. On one occasion it is stated that this person was left on the floor for one hour before the ambulance service was contacted but no explanation to support their reasoning for this. In a risk assessment that was completed on the 18 September 2008 with regards to this individuals personal care needs it is noted,’ Could slip when carrying out the task’. In the section, risk to self and others it stated, ‘X to be supported by one carer when carrying out any personal hygiene tasks’. Also we could find no risk assessment specific to this person when shaving but there are daily recordings and accident records where this person has experienced a cut with their shaver. Further evidence of the homes lack of risk management was that a rabbit has been purchased for one individual but this is now causing some concern as the rabbit is now scratching this person. We did not evidence within this persons care record as to why the rabbit had been bought and/or how this decision was arrived. We could not find any risk assessments that had been put in place so that people living in the home feel confident that they are being protected and their rights are upheld. Without consistent risk assessments in place to cover all aspects of a person’s daily life the home are not being seen to protect people sufficiently from harm or injury. Daily records are completed for each person living at the home. These give an insight into the person’s routine each day, their state of wellbeing and any appointments they have attended. However these now require further work to ensure that staff give a clear explanation of situations they find with what The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 13 action has been taken and these recordings need to correspond with accident records (further details in complaints and protection section). We found no evidence that would suggest that all people are consulted individually or collectively on all aspects of their lives with the home. For example, there is recording of residents meetings and the home have only just began to introduce a key working system so that each person has an individual meeting with their key worker to discuss their support. Staff confirmed that residents meetings are not taking place. People in the home have a range of needs including communication, behaviour and sensory. In the main staff were seen to verbally communicate with people but it is recommended that other forms of communication be explored, such as, the use of photographs, pictures and objects of reference in order that all individuals can be involved in choices, decision making processes and creating their own individual lifestyle plans. We expressed our concerns to the acting manager with regard to care planning and risk assessments now needing to be in place for all individuals in a consistent manner. Without these staff have no information on which to support individuals in a consistent and safe way. The acting manager acknowledged the shortfalls and is trying to rewrite each individuals care plans and out of the four people living in the home there are now two left to do. However, care planning and risk management have been outstanding from previous inspections. The home is consistently not protecting people who live in the home with some of their current practices in care planning and risk management. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 14 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, 15, 16 & 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Efforts are being made to support individuals to develop their life skills and to participate in activities that meet their needs but risk strategies are not always observed in this process. EVIDENCE: We talked to people who live in the home, staff and examined records and found efforts are now being made to record people’s activities. It was recorded that some people attend college; individuals are encouraged to undertake independent living skills and some opportunities for people to access activities in the wider community. One person’s record of activities states that they went to a hospital appointment visit. This was pointed out to staff that this is not an activity and therefore should not be included as one but should be included in the person’s daily recordings. It was positive that staff are recording when people are declining a particular activity but this needs to be supported with an explanation as to why for future planning purposes. There The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 15 is no evidence which would support how individual’s activity choices have been made. For example, one person is going to college one day a week but the acting manager has now identified that this person may be getting bored when at home. Therefore the acting manager asked at a local motorcycle shop whether this person could spend some time there. There is no evidence that would suggest that the acting manager had risk assessed this community activity so that the person would be protected from any risks. On the second day of our inspection we were informed that people living in the home would be going on holiday for five days the following week. We asked whether this holiday had been risk assessed for people and the acting manager confirmed that it had and families had been informed. However, the acting manager had not informed the local authority about these plans and we recommended that this should now take place. Positively people shared with us their thoughts in relation to going on holiday, ‘I need a break from here’. ‘We are going to buy our holiday things’. A person came back from college and said that they had been typing and had really enjoyed this. Another person had been to the local shops. We observed a person undertaking some cleaning tasks and hanging out washing. Staff told us, ‘It is their individual living skills day’. One person showed us some photographs of them and members of their family. This person was excited and said, ‘This is me and this is my sister’. They appeared proud in showing us these photographs. This person also enjoys writing down weather conditions and proudly gave us predictions they had collated from the television. A person showed us a large poster that they had got whilst out and how they were interested in films. This provided a ‘talking point’ and they said, ‘Where do you think we should put it?’ It is now recommended that lifestyle plans are completed with people which include photographs and pictures that tell a story in relation to getting to know our people feel and what their choices are in relation to their lifestyles therefore giving meaning to individual’s lives. One individual living at the home is now growing older and staff were sharing with us that they don’t feel that this person should be going to a park now the weather is getting colder and it does get quite muddy. This person is pushed in a wheelchair when out in the community. However, we did not evidence any activities that had been appropriately devised for this person. We did observe on one day that a member of staff took this person out in their wheelchair for a walk but there we did not evidence a programme of activities that would be held in the home. It is now recommended that activities are evaluated in order that the home can monitor that activities meet individual’s expectations and needs. During out inspection we observed that daily routines, where possible, are flexible. It was positive to see individuals in the kitchen making drinks and enjoying making drinks for visitors, thereby promoting peoples independence The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 16 and self worth. Staff were seen spending time with people and in the main treating individuals with respect and courtesy. Staff confirmed that informal discussions took place in relation to what meals would be included in the menu but there was no recorded evidence to support this. People are now supported to choose a meal they would like and peoples names are listed on the homes menu next to the night that their meal would be served. Menus do not have pictures to illustrate the individual meals served, for example, for the breakfast menu there are choices with a picture of toast popping up in a toaster and for lunch there is a person stirring a pan on a cooker. Specific pictures are used to illustrate meals so that all people can be involved in decision making. Also staff need to find other ways of involving people as one person does not have their choice on the menu. We observed peoples meals and on one occasion it was a person’s birthday which positively the home celebrated with a chocolate cake. However, it became difficult to manage an individual who wanted to have some chocolate cake but it was not appropriate for them due to their medical condition (diabetes). Nutritional assessments need to be undertaken for all people living in the home and staff should receive some training in respect of meal options that are balanced and healthy. This will help monitor that the dietary needs of individuals are identified and managed safely. It was positive to note that on the second day of our inspection a senior carer had been with this individual to the diabetes clinic and it was reported to be worthwhile. This person was advised about appropriate foods and what to eat. This individual will now be going regularly to the diabetic clinic and a specialist will also be visiting the home to ensure staff are made aware of what foods are appropriate. People spoke about their enjoyment of being able to have a night where they choose a meal. As on person explained, ‘I like stew and dumplings’. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Generally people are encouraged to maintain their own independence in relation to completing their personal care tasks on a daily basis in a way they prefer. There is a lack of knowledge around certain health conditions and how individuals should be supported. The homes medication practices are placing individual’s health and wellbeing at risk from potential medication errors. EVIDENCE: We observed that people were being supported to maintain their own personal care; people were wearing clothes appropriate to their age, gender and weather conditions. Staff were seen to promote individuals dignity and privacy by ensuring personal care is undertaken in private. As mentioned earlier in this report care plans and risk management systems must be improved. This also applies to care planning for health needs. Health action plans require further work to ensure that staff are following these so that peoples health and wellbeing is not being compromised. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 18 We looked at the homes medication system and found a number of areas, which required improvement. The registered proprietor and acting manager told us on the 14 October 2008 that the home was in the process of changing pharmacy suppliers due to take place Friday 17 October 2008. We stressed that in the interim staff must ensure people receive their medication as prescribed by their doctor with a safe system of administration, (detailed further in conduct and management). We were particularly concerned about three individuals who administer their own medicines. Whilst it was positive their independence was being promoted there were insufficient safeguards and monitoring arrangements in place. The written risk assessments were not individualised or specific; the new medication care plan for the person with diabetes did not reflect the actual practice of self-administration. The medicines were not stored safely in each persons bedroom. We saw that one persons medication container, (Nomad cassette), was left on top of the DVD player in their bedroom, which had the door propped open. Neither of the other two people’s medication was locked securely away in their bedrooms. This meant that other people living in the home were exposed to serious risks of harm. We looked at the Medication Administration Record (MAR) sheets for each person. We noted that the MAR sheets for one individual with diabetes had no signatures to demonstrate whether the medication had been administered or code entered to demonstrate a reason for non-administration. We discussed this persons medication with the acting manager and senior carer who told us that this person administers their own medication. There was a risk assessment completed by the registered manager; however the information was insufficient and did not reflect the medication being self administered or monitoring arrangements and it had not been reviewed in the past twelve months. This clearly identified that the current medication practice did not follow the homes own written guidance and further illustrates the lack of staff members understanding together with the information found in risk assessments. We also noted that the medication for one individual was in the original container but we could not accurately audit this medication to ensure that it had been given as prescribed by their doctor. This was due to there being no ‘carried forward’ balance on the MAR sheet so we were unable to verify the number of tablets or doses administered. There were similar issues with this persons other tablets. For example, the medication covered also contained a box of tablets with the persons name handwritten on the box. They were nineteen tablets left but no dispensing label or date of dispensing and no indication on the MAR sheet as to whether this was prescribed medication. The acting manager and staff who were on duty at the home were unable to locate information relating to this matter. We were concerned that this practice did not provide safeguards for individual’s health and well-being. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 19 At a previous inspection on the 12 June 2008 we had noticed that the fridge temperatures were excessive on occasions. We issued a requirement for the registered person to investigate and rectify the fridge temperatures to make sure that the daily temperature was maintained between 2° C - 8° C. This was particularly important for the storage of insulin. We examined the fridge temperature records and noted that there were some omissions and that on occasions the temperature had been recorded as 9° C. The home should obtain a fridge thermometer to record the daily minimum and maximum fridge temperatures, which should be recorded once daily, together with any corrective action required to maintain the fridge temperature between 2C - 8° C. We were also seriously concerned about the support and monitoring arrangements for a person with diabetes. The acting manager could not tell us what this persons blood glucose (BM) normally should be, there were omissions in the BM records, which showed excessive fluctuations. There were no specific or detailed food records for this person and little evidence they were being supported and encouraged to follow a healthy diet. We were told, X had to have what was their choice. There was little understanding from the staff, apart from one senior carer about the consequences for this persons heath and wellbeing. We noted on 14 October 2008 that their BM was 5.5 before breakfast, 14.6 before tea and this person was encouraged to test again at 8-20 in the evening with the result 19.2. The latter reading was taken because the resident wanted to have chocolate birthday cake with the rest of the people living in the home to celebrate someones birthday. As we were there staff tried to persuade this individual to have water only but we noted they eventually helped themselves to yogurt and biscuits. The lack of care planning, monitoring and training in this area is unacceptable as it places individuals at undue risk of harm. At the time of our inspection we requested that staff check a person’s weight as from observations it looked as though they were losing weight. We were informed that the homes scales may not be working correctly and we therefore requested that these should now be calibrated so that people’s weights are recorded accurately to be confident that the person is not at risk from underlying health needs. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People do not have access to a complaints procedure that they are able to understand. People are not safeguarded by the homes practice of recording and reporting indicidents. Some recruitment practices are not safe and do not offer safeguards to people living in the home. EVIDENCE: The acting manager confirmed that the home has received no complaints. However, the Commission for Social Care and Inspection (CSCI) have received a complaint in May of this year. Following this the registered manager has been suspended from her duties in the home and the local authority is currently investigating the concerns raised. The home does not have a pictorial complaints procedure that people living in the home would be able to understand. Therefore it is recommended that the home devises one and that each person has a copy of their own. We found evidence that the home has informed us of some accidents and/or incidents but these were not being recorded or reported in a consistent or timely manner. On the first day of our inspection the acting manager confirmed that the home has completed three notifications in line with Regulation 37 of the Care Home Regulations 2001. However, on the first day of our visit two of these could not be found. One of the incidents was documented on the 1 October 2008 and this has been investigated by the The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 21 police under adult protection procedures. The member of staff has currently been suspended from their duties whilst investigations continue. We examined care records and accident records and found that there are a number of incidents involving people living at the home. There were five, which occurred between the dates 27 September 2008 to the 6 October 2008. On the 11 October 2008 an individual was found with blood around their mouth area. However, there is no record to inform the reader why there was blood and what happened next in daily recordings. There was also no accident/incident record completed for this. On the 6 October 2008 there is an accident report completed stating, ‘X had tried to shave cuts to cheek bone and under jaw’. However, there was no corresponding daily recording to correspond with this to show actions taken or risk assessment analysis. On the 30 September 2008 this person had tried to shave themselves and it was recorded in accident report, ‘small cut on chin’ but no corresponding daily records with risk analysis or what action taken. All accident records and care records should correspond and these should be documented actions taken and risk assessments in place to try to prevent accidents. Care plans and risk assessments must be implemented for all behaviours. These must include instructions on triggers, diversion tactics, and forms of behaviour, frequency and associated record keeping. In addition to this the acting manager and registered proprietor should complete an analysis of indicidents in order to inform the reviewing of behaviour guidelines. Guidelines’ should also be agreed within a multidisciplinary forum. This offers greater protection to people living in the home. We examined people’s records for monies held on their behalf by the home and found that there was some discrepancy with the way staff had calculated monies going out and monies left. The registered proprietor observed this with us and will now ensure that staff are made aware of the correct procedures to follow. Recruitment records sampled showed that a robust procedure is not being followed for the protection of people living in the home (discussed further in the staffing section of this report) with regard to ensuring Criminal Bureau Records (CRB), Protection of Vulnerable Adults (POVA) and staff training is in place. Improvements must be made in this area to offer further safeguards to people. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 22 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 judgement has been made using available evidence including a visit to this service. Furnishing is currently being replaced together with some decoration work being undertaken. Some areas of the home are continuing to pose health and safety risks to the people who live there. EVIDENCE: We undertook a tour of the premises on the first day of the homes inspection and identified a number of outstanding serious concerns. The floor covering to the first floor landing, shower room and threshold from the landing to three people’s bedrooms was badly damaged, torn, frayed and lifting, posing a tripping hazard and a risk to individuals’ safety. This had been previously identified at the random inspection on 12 June 2008 and remains outstanding. We saw that a bathroom mat had been placed over the defective area, preventing the shower room door from closing. The registered proprietor had assured us that all immediate requirements had been actioned and this is The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 23 further evidence of the homes lack of timely action which places people’s health and safety at risk. We also noted that none of the wardrobes, some with items stored on top, were secured to the walls, posing risks to the individuals. When we returned to the home on the 23 October 2008 the work to the shower room was still ongoing and the work men were not at the home which further indicates the homes lack of timely action. On a positive the lounge area now has two new two seated sofas, one three seated sofa and one comfortable armchair and the room has been decorated in neutral colours that are relaxing to the eye. This is an improvement from the homes random inspection on the 12 June 2008. However, there is a multi plug socket on the floor near the television that has no written risk assessment which was previously made a requirement in October 2006. It was encouraging to see that the stairs and landing have been redecorated and looks clean and fresh. We found that the landing light bulb was not working. Folding doors leading to access to the boilers needs to be secured which was done during our visit. Staff need to be instructed to make sure it is locked at all times. The hallway has some broken floor tiles that are covered with clear tape adjoining an edging strip which must be properly repaired to minimise the of risk of trips or falls, especially for one older individual with Parkinsons Disease due to their unstable and poor mobility. We were told that the home was awaiting new carpeting for this area. There was a mattress, bed base and furniture items on the landing. We were told that there are no storage facilities, these items pose a risk to people living at the home. This is also further evidence of the home having no risk assessment in place. We looked at peoples bedrooms with their permission and found one persons ground floor bedroom is still to be decorated with some outstanding repairs which were noted at the homes last inspection. For example, the en-suite bathroom’s light bulb is not working and therefore no light source in this room, there is no call cord in the call system and the headboard needs to be secured in position. Another bedroom on the first floor had the door unlocked. as the individual self-medicates this poses a risk to other people living in the home. This bedroom has not been decorated as yet, but this person has chosen their curtains and furniture. Another individual’s bedroom had been repainted and a new carpet had been fitted. This person proudly showed us their room, which they told us they were very pleased with, and they serenaded us with their electronic organ and guitar. This individual said they were having a new desk and armchair and that they wanted a new desk because the one they had wobbled. There was no lamp shade on the ceiling light but we were told there was one already to be put in place. This person administered his own medication but it was not held securely in the room and this again posed a risk to the other people living in the home. Individuals were able to choose their own wall colours and in the main individuals were happy with their newly decorated rooms. We observed a lot The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 24 of personal items in bedrooms which reflected people’s interests and personality. All items were rearranged to individuals own liking. There is outstanding work to be done in individuals bedrooms as already cited, such as, securing wardrobes, no cord in some people’s call systems and new lights needed in shaver units. The home must now remedy all of the work that pose a risk to peoples health and safety which includes ensuring that doors are locked and medication is not on show in peoples bedrooms who self medicate. We found that mops were colour coded identifying the different areas within the home that each is used in line with recommended guidance. However, there was no laundry procedure or infection control guidelines displayed in relation to a cleaning schedule to ensure that mop heads were laundered daily at thermal disinfectant temperature, for good infection control purposes. The garden area of the home is pleasant with an area of grass and a small pond which has fish in it. One individual feeds the fish and enjoys showing visitors the gardens pond area. All people were using the garden when we visited for sitting in and hanging out washing. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 25 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, 34 &35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Individuals are not always supported by qualified competent staff due to inconsistent and unsafe staffing levels. Some recruitment practices do not offer sufficient safeguards to people living in the home. EVIDENCE: Staffing levels are not maintained to meet the assessed needs of individuals living in the home. This means their needs might not be met safely. We asked the acting manager and registered proprietor what staffing levels should be in place for the six people currently living in the home. We were informed that there should be two members of staff in the morning, afternoons, evening and through the night. However, on the day of our first visit, the 14 October 2008, we arrived at the home at 7:30 in the morning and discovered that there was only one member of staff on duty who was a care assistant. The other member of staff, a senior carer, had taken one person to catch the train into Birmingham to meet the acting manager so that they could be taken to a hospital appointment. The senior carer then proceeded to catch the train back to the home and would continue with their shift. The senior carer had just completed a ‘sleep in’ shift at the home. Another senior carer who was due to The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 26 undertake the shift that morning had contacted the home at 4-30 am stating that they were not coming into work that morning due to feeling ill. This left one member of staff at the home with five people who live at the home. There should be a minimum of two staff on duty at the home to ensure the health, welfare and safety of the people living there. This situation was similar with regards to staffing levels as was found at the homes random inspection on the 12 June 2008 when a member of staff was left alone with people during a peak time of activity when individuals are getting up, needing breakfast and getting ready for the day. The registered proprietor acknowledged the situation and attributed it to what he described as a staffing crisis. The registered proprietor told us he had tried to recruit more staff but that there had been a poor response to interviews and even to submitting applications. The registered proprietor told us that he was now aware of the issues and that he now visited the home three days each week. Due to our concerns we issued an immediate requirement instructing that staffing levels are maintained at a safe level for the people living in the home at all times. Current dependency levels of people living in the home together with four weeks staffing rotas must be submitted to the Commission. We also informed the acting manager and registered proprietor that the Commission may consider enforcement action. In addition to finding only one member of staff on duty on the morning we visited there were also two workmen undertaking some decoration work at the home. The workmen had no CRB clearance as required for all people working in the home , and no public liability insurance. They had free access to all areas and could not be supervised with just one member of staff on duty. The registered proprietor told us that he knew these workmen personally and could vouch for them, and offered to personally supervise the workmen during the entire time they were on the premises. There were no risk assessments in place and the acting manager was unable to devise a written risk assessment with immediate effect. An immediate requirement was issued instructing that the work men must cease work at the home until safeguards are in place to ensure the people living in the home are protected from harm and/or injury. We also copied documents under Code B of the Police and Criminal Evidence Act and informed the acting manager and registered proprietor that the commission may consider enforcement action. We noted from staffing rotas that the members of staff that complete the overnight shifts were not senior carers. One member of staff who was employed by the home as a care assistant was working as a ‘waking night’ and was noted on the rota to be on shift for nine nights over the period from the 14 to the 30 September 2008 and nine night shifts from the 1 to the 17 October 2008. On looking at this staff members recruitment file we saw documentation that confirmed that they had a student visa for this country and therefore should only be working twenty hours per week. However, in one week, Sunday the 14 to Sunday the 21 September 2008 they were working five night shifts. They are also a fairly new member of staff having very recently commenced employment at the home. This means that they were left in the The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 27 responsible position of providing care for four people who were seen to have complex and diverse needs. Due to our concerns we issued an immediate requirement instructing that competent, suitably qualified and experienced staff appropriate should be on duty especially during the night hours. We also copied documents under Code B of the Police and Criminal Evidence Act and informed the acting manager and registered proprietor that the commission may consider enforcement action. We looked at staff recruitment files and noted that a number of records had important information missing that needed to be there to ensure that people’s health, safety and wellbeing were not compromised. For example, on one staff file there were no references, no POVA First or Criminal Record Bureau (CRB) clearances filed. Also their visa was only for a period of residence and this was due to expire on the 31 October 2008 with no information to support further applications to extend their stay in the country. This member of staff was on a students passport. There was no clear documentation that noted when this person began their employment and their contract was unsigned and not dated. Another recruitment file was looked at of a senior carer, who commenced their employment with the home on the 1 September 2008, there were no references. There was also no date or signature on this persons contract. On another recruitment file there was no documentation to show that the person had applied to remain in this country but there was a Criminal Record Bureau disclosure dated September 2008. We spoke to this member of staff who confirmed that they had information to state that they could remain in the UK until June 2009 and would bring this into the home. Due to our concerns we issued an immediate requirement instructing that all documentation stored on staff member’s recruitment files is in place ensuring that people living in the home are safeguarded by the homes recruitment procedures. We also copied documents under Code B of the Police and Criminal Evidence Act and informed the acting manager and registered proprietor that the commission may consider enforcement action. Within the recruitment files that were sampled there was lack of information in relation to some staff members mandatory training attained, such as health and safety, moving and handling, safeguarding, first aid, fire safety, food hygiene, infection control, challenging behaviour and risk assessment. Also there was no evidence in relation to more specialist courses, for example, nutritional screening, diabetes, epilepsy or Parkinson’s disease. This made it difficult to confirm that the home were maintaining staff training so that people who live in the home were safeguarded by the homes recruitment and training methods. We were told that all staff apart from one person has received accredited medication training. However when we looked at medication training certificates the home was not able to demonstrate that all of the medication training was accredited for the safe handling and administration of medicines. For example, a new member of staff personnel file showed that they had only received basic medication awareness. Medication systems require improving to ensure greater protection to The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 28 individuals. It is recommended all staff involved in medication administration should date and sign to indicate when they have read the new procedure to demonstrate their understanding and compliance. We could find no documentation in relation to staff meetings that have taken place this year but we were assured by the acting manager that a staff meeting would be taking place on the 16 October 2008. There should be at least six a year to ensure staff know about the changing needs of the people living there and are kept updated with ‘best’ practice. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 29 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 &43 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The management arrangements do not ensure the people living there benefit from a well run home. People cannot be confident that their views underpin the development of the home. Arrangements do not ensure that the health, safety and welfare of the people living there is promoted and protected so ensuring their safety and well being. EVIDENCE: The registered manager is currently on long term leave from the home and Ms Sharon Martin has been employed on a three month contract as acting manager. Ms Martin told us that she has worked in care since leaving school and had achieved National Vocational Qualifications (NVQ) Level 2, 3 and 4. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 30 Ms Martin has completed the registered manager’s award. There was no evidence on Ms Martin’s personnel record of a contract and Ms Martin confirmed that she did not have a written contract of employment or a job description. Evidence is cited throughout this report that all the needs of people living in the home are not being met, and in some instances this is placing individuals at risk of serious harm and/or injury. For example, there are major omissions in care planning and risk management, health needs, management of medications, inconsistent staffing levels and staff recruitment practices are placing people at risk. We were also very concerned about the management arrangements and the acting managers decision-making when we arrived at the home on the 14 October 2008. This was in relation to the acting managers knowledge that one carer would be left at the home with the people who live there (as detailed in staffing section) especially given the risks identified on examination of the accident records. The situation was a repeat of the situation found at the random inspection on 12 June 2008. Throughout this report there is evidence of risks that have not been assessed or managed appropriately. For example, we observed four open tins of paint and five litre container of white spirit left on the floor in the rear hallway, accessed by residents going to and fro. We raised this issue with the acting manager and the registered proprietor (both of whom were at the home) and requested that these hazardous chemical materials were removed from the public area and stored securely with immediate effect. There were no written risk assessments for the painting and decorating work being undertaken at the home whilst the people living in the home were around. The acting manager was unable to complete the written risk assessments because there was no access to do so on the homes computer and there were no hard (paper) copies. The registered proprietor asked us to explain what risk assessments were and acknowledged his ignorance about what needed to be done. Another example of poor management is in relation to the homes medication systems when a senior carer told us that the pharmacy has taken over ordering medication directly from the doctor and keeping copies of medication prescriptions. This was a change to the previous medication ordering practice and directly conflicts with the guidance issued by the RPSGB (Royal Pharmaceutical Society of Great Britain). We informed the registered person and the acting manager that this practice must cease immediately and the home must follow best practice guidance at all times to safeguard the health and welfare of the residents. On Tuesday 14 October the home were unable to produce a number of service maintenance certificates to show that the premises were maintained in a safe condition, these included the fire alarm system service, portable electrical appliances (PAT) test and Landlords Gas safety certificates. On the 23 October 2008, we were told by the acting manager that they had become aware on the 15th October that there were defects to the insulation of the wiring of the fire The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 31 alarm system. This had been previously identified by a contractors service visit around May or June 2008. The contractor’s report of the visit identified that urgent remedial work was required as the insulation for the fire alarm system wiring would only provide five to six minutes fire alarm warning instead of the required thirty minutes (British Safety Standard). The acting manager told us that the contractors were due to give the home a quotation for the work on the 23 October 2008 but there was no firm commitment that the work would be undertaken or timescale for completion. We immediately contacted the West Midland Fire Service to alert them to this situation. A fire safety inspecting officer attended the home within twenty minutes of our telephone call due to the serious nature of the risk to people living and working at the home. The fire safety inspecting officer stated that the home now requires this urgent rewiring work completed immediately as the current wiring will not ensure that people living at the home will be protected from fire. Due to our concerns we issued an immediate requirement instructing that action be taken immediately to ensure the rewiring work is completed as per the instructions of the fire inspecting officer so that people are protected from the risk of fire. We also copied documents under Code B of the Police and Criminal Evidence Act and informed the acting manager and registered proprietor that the commission may consider enforcement action. The immediate requirement stated that the home must now complete a full risk assessment in terms of fire safety to CSCI in writing by Tuesday 28 October 2008 together with a copy of the formal confirmation from the homes contractors, which states the date, when this work will commence. We found no evidence of any quality assurances systems in the home for monitoring standards and improving the outcomes for people living in the home. The registered proprietor and the acting manager acknowledged that the home does not have any quality assurance monitoring systems. On a positive note the acting manager confirmed that she has now reimbursed people for the last three years in respect of their mobility allowance as was strongly advised in a safeguarding strategy meeting held on the 30 September 2008. The home is now noting when the homes minibus is being used within daily recordings for evidence purposes. The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 32 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 1 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 1 25 2 26 2 27 1 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 1 1 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 1 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 1 X 1 1 1 1 1 1 1 The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 33 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. 2. Standard YA6 YA9 Regulation 12 13(4)(c) Requirement Care plans must be implemented for all residents needs to ensure these are managed safely. Individual risk-taking assessments must be undertaken on all residents and regularly reviewed, i.e. with regard to challenging behaviour, wheelchair users etc. The registered persons must ensure that resident’s medication is administered or supervised at the correct time of day as prescribed by a medical practitioner to ensure that residents who use the service have their health and well being maintained and safeguarded. The registered persons must ensure that documented advice and support is sought urgently from the professional health care specialist diabetes service for the resident with unstable diabetes and that the advice is followed diligently. The registered persons must investigate and rectify the excessive temperature recordings for the domestic DS0000063539.V368013.R01.S.doc Timescale for action 30/11/08 30/11/08 3. YA20 13(1)(2) 24/10/08 4. YA19 13(1)(2) 15/10/08 5. YA20 13(2) 25/10/08 The Limes Blackheath Version 5.2 Page 34 6. YA23 13(6) 7. YA23 13(6) 8. YA23 23(4) 9. YA24 13(3)(4) fridge used to store food and medication (especially Insulin) and ensure the fridge temperature is maintained between 2C and 8C at all times, for the residents health and well being. The registered persons are required to ensure safeguarding referrals are made to Sandwell MBC, CLDT, in a timely manner and in accordance with the Safeguarding procedure to protect residents from risks or harm. The registered persons must also ensure that with immediate affect, CSCI must be notified by telephone, on the same day when any event affecting the welfare of the residents is known and that this must then be reported in accordance with Regulation 37. (This is a breach of a previous immediate requirement issued on the 12 June 2008). The registered persons must ensure that adequate precautions against fire after consultation with the fire authority. This is to ensure that people live in a safe and well maintained environment free from the risks of fire. The registered persons are required to undertake a documented health & safety audit of the premises, from which written risk assessments must be implemented / reviewed and action taken to safeguard the residents from risks of harm within identified timescales. To include the following: (1) The wardrobes must be secured in all bedrooms and 15/10/08 14/10/08 04/11/08 30/10/08 The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 35 10. YA24 13(3)(4) 11. YA24 13(3)(4) items removed from the top of the wardrobes which are posing a risk to people. (2)To carry out a written risk assessment with regard to the use of multiple electrical adaptors. (This is not an exhaustive list) To progress plans to replace worn flooring in the first floor shower room so this is a pleasant and safe facility for people to use. (This is a breach of an immediate requirement issued on the 14 October 2008). The registered persons must take immediate action to rectify the badly damaged, torn, frayed and lifting floor landing, shower room and threshold from the landing to three resident’s bedrooms, posing a tripping hazard and risk to resident’s safety. 14/10/08 30/10/08 12. YA24 13(3)(4) 13. 14. YA32 YA33 18(1)(c) 12(1) The registered persons must 30/10/08 take immediate action in line with the instructions provided by the fire service to make sure the small office, with large boilers, also used to store a large number of files and which is excessively hot and had no visible means of ventilation is not a fire risk. To provide specialist training for 30/12/08 all staff in diabetes and epilepsy awareness. The registered persons are 14/10/08 required with immediate effect to ensure that there are at all times suitably qualified, competent and experienced persons working at the home in such numbers as are appropriate for the health and welfare of residents living in the home. This includes the night time hours, when care DS0000063539.V368013.R01.S.doc Version 5.2 Page 36 The Limes Blackheath 15. YA24 13(4) 16. YA33 13(4) 17. YA33 12(1) assistants have been used and are working alone. (This is a breach of a previous immediate requirement made on the 14 October 2008). All parts of the home to which residents have access are so far as reasonably practicable free from any hazards to their safety. Any activities in which residents participate are so far as reasonably practicable free from avoidable risks and unnecessary risks to health and safety of residents are identified and so far as possible eliminated. (This is a breach of a previous immediate requirement issued on the 12 June 2008). The registered persons must undertake written risk assessments from which documented risk management strategies must be put in place. You are also required to ensure that there is a named, suitably qualified, competent and experienced person designated to take responsibility for the running of the home and for the health and welfare of residents living there on all shifts. (This is a breach of a previous immediate requirement issued on the 12 June 2008). The registered persons are required to undertake a documented assessment of resident’s dependency levels, and submit this assessment with a staffing proposal and a copy of four weeks staffing rotas for consideration by the CSCI. This is to ensure that all residents’ needs are met and their health and safety is assured. (This is a breach of a previous immediate requirement issued on the 12 DS0000063539.V368013.R01.S.doc 14/10/08 14/10/08 14/10/08 The Limes Blackheath Version 5.2 Page 37 June 2008). 18. YA33 12(1) The registered persons must provide a documented analysis of the impact of ancillary duties undertaken by care staff so that all residents needs can be met in a timely manner. (This is a breach of a previous immediate requirement issued on the 12 June 2008). The registered persons must ensure that a Regulation 37 notification is submitted for any occasions where there are staffing shortfalls, with contingency measures clearly identified. This is to ensure that the health and well being of residents is safeguarded. (This is a breach of a previous immediate requirement issued on the 12 June 2008). To ensure that all staff receive a minimum of six recorded supervision meetings per year together with an appraisal system. To provide training for all staff commensurate with their duties which include: 1) Moving and handling. 22. YA42 13(4)(c) 2) Infection control. The registered persons must 24/10/08 ensure that there is more regular testing and recording of water temperatures (i.e. monthly) so that resident’s health and safety are assured at all times. The registered person must 24/10/08 ensure that there is more consistent weekly testing and recording of the fire alarm system to ensure that safeguards are in place to protect residents from fire. DS0000063539.V368013.R01.S.doc Version 5.2 Page 38 14/10/08 19. YA33 13(4) 14/10/08 20. YA36 18(2)(a) 24/10/08 21. YA42 18(1)(c) 30/11/08 23. YA42 13(4)(c) The Limes Blackheath 24. YA42 13(4)(c) 25. YA34 1913(6) 26. YA34 1913(6) 27. YA34 1913(6) 28. YA34 19(1) To carry out written risk assessment for all Control of Substances Hazardous to Health (COSHH) products, which are used to promote health and safety practice within home. To ensure that risks are fully explored with regard to starting new staff whilst awaiting the completion of a satisfactory CRB check (and to forward a copy to CSCI). To ensure that fully completed health declarations are received prior to appointment of potential new staff (as this must help form judgements as to whether the candidate is physically and mentally fit for the purpose of work that he is to perform). To ensure all agency staff who are employed have received a CRB and POVA check within the last 12 months with written confirmation obtain from the agency and held on the premises. You shall not employ any person to work at the home unless, they are fit to work there and you have the required information and documents. 24/10/08 14/10/08 14/10/08 14/10/08 14/10/08 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. 2. Refer to Standard YA1 YA5 Good Practice Recommendations To amend Statement of Purpose and Service User Guide to ensure it accurately reflects service provision and complies with current Standards and Regulations. Contracts of residency should be maintained in the home in order that the registered persons can monitor resident’s DS0000063539.V368013.R01.S.doc Version 5.2 Page 39 The Limes Blackheath 3. YA6 4. 5. YA6 YA6 rights are being upheld. To carry out a review of all service users individual behavioural management programmes. To ensure that there are explicit guidelines for staff to follow based on professional best practice. To introduce a person centred planning process to assist service users with developing their care plans. To continue to pursue plans to ensure that service users’ needs assessments and care plans are reviewed on a six monthly basis as part of a multi-agency approach involving other significant professionals. To consider strategies for improving record keeping by staff to ensure that: - Daily reports reflect goals and objectives identified in care plans. - Descriptions of how challenging behaviour is diffused correlates with behavioural management guidelines or explanations are given as to why this is deviated from. - There is more accurate correlation between service users’ activity plans, practice, and records of activities and outings. Where any restrictions are made on a resident’s right to make their own decisions, this must be discussed with all relevant people, agreed, recorded and regularly reviewed. For example, with regard to financial decision making. Other forms of communication should be explored such as the use of photographs, pictures and objects of reference in order that all residents can be involved in decisionmaking processes. Action should be taken to ensure protocols are introduced when the decision is made that someone lacks capacity. This will help promote their rights and compliance with the Mental Capacity Act. To undertake a review of individual activity programmes in consultation with service users with a view to increasing the number of leisure and social activities (in-house and community based). Nutritional assessments should be undertaken for all people living in the home. This will help monitor that the dietary needs of residents are identified and managed safely. Health action plans should be completed in full and any agreed actions evidenced. This will support a holistic approach to health management. Suitable numbers of staff should receive training in adult DS0000063539.V368013.R01.S.doc Version 5.2 Page 40 6. YA6 7. YA7 8. YA8 9. YA12 10. YA17 11. 12. YA19 YA23 The Limes Blackheath 13. YA33 protection and aggression in order to reduce risks to residents. To continue to pursue the recruitment of male staff. Not Met at the Random Inspection 12/06/08 A training matrix should be developed in order that the home can monitor that suitable numbers of staff have up to date training to meet resident’s needs. It is recommended that the home is enabled to access and use e-mail and web site facilities to assist with communication and researching current good practice and guidance Effective quality assurance systems must be developed by the home. This must include an annual development plan must be devised based on a systematic cycle of planningaction-review, reflecting aims and outcomes for people living in the home. Quality monitoring processes should continue to be implemented in order that the home can measure if it is achieving its aims and objectives. The home should be able to demonstrate all staff have participated in a fire drill and this is maintained on at least a six monthly basis. This will help reduce the risk of injury to residents in the event of a fire. An analysis of accident records should be undertaken and where necessary action taken to reduce risks to people. 14. 15. YA35 YA37 16. YA39 17. 18. YA39 YA42 19. YA42 The Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 41 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 Limes Blackheath DS0000063539.V368013.R01.S.doc Version 5.2 Page 42 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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