Inspection on 24/08/05 for The Limes Blackheath

This inspection was carried out on 24th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Limes Blackheath 17/04/09

The Limes Blackheath 14/10/08

The Limes Blackheath 26/10/06

The Limes Blackheath 31/01/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 The Limes 37 Avenue Road Blackheath West Midlands B65 0LP Lead Inspector Jayne Fisher Announced 24 August 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Limes Address 34 Avenue Road Blackheath West Midlands B65 0LP 0121 559 3935 0121 561 1333 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr. Mohammed Iftikhar Ali Ms. D. Bennett-Hopper (Acting) Care Home 8 Category(ies) of LD - Learning Disabiltiy (8) registration, with number of places The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22nd Februray 2005 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 disatnce 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 bedrroms, four of which have en-suite facilities. The communal facilities on the ground floor consist of a lounge/dining area, conservatory and kitchen. Toliets 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. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between the hours of 11.30 a.m. and 6.00 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: formal interviews with the deputy manager, two support staff who were on duty, and observations of care practices. There was also a tour of the premises. The home provides care for eight residents who have learning disabilities. All residents were at home during the inspection. All were happy to be interviewed and participate in the inspection; they either gave consent, or showed the inspector their bedrooms. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of including an action plan submitted by the home following the last inspection. At the beginning of the year the home underwent a change in ownership and management. The inspector was made to feel very welcome and would like to thank service users and staff for their assistance and co-operation during the visit. The manager was on holiday but the deputy manager and staff on duty ably assisted the inspector. Unfortunately, some records were not accessible and therefore progress could not be evaluated in respect of some outstanding requirements. What the service does well: Residents have unrestricted access to all parts of the home and are encouraged and supported to make their own decisions with regard to their daily routines. For example, during the inspection residents chose to either sit in the communal lounge watching television or reading the newspaper (which they had fetched themselves), or were in their own bedrooms listening to music or watching television. The atmosphere was happy, relaxed and friendly through out the day. Residents joked between themselves and with staff; one resident was singing a holiday tune. Residents were looking forward to a forthcoming holiday which they confirmed they had chosen themselves. There were lots of positive comments made by residents about various aspects of their lives at the home and staff who supported them. One resident stated “I like the staff, I like them all”. Staff fully encourage residents to maintain their independence. Residents have keys to their own bedrooms and have tea and coffee making facilities in their rooms. Residents were seen assisting with making drinks and preparing food in the kitchen and were involved in a variety of housework tasks. Residents are encouraged to take responsibility for their The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 6 own medication and monitoring of their own health care with assistance as and when needed. Staff fully encourage residents to maintain family links. A lot of effort is made by staff to ensure that meal times are pleasurable and enjoyable. Meal times are leisurely and staff constantly ask residents if they have had enough to eat. Residents enjoy a varied and well balanced diet. All parts of the home were found to be clean and tidy. Residents have personalised own bedrooms with photographs, pictures, ornaments, televisions and music centres. There is a competent and qualified staff team who through interviews and observations demonstrate a dedicated and caring approach to residents. What has improved since the last inspection? What they could do better: The statement of purpose and service user guide need further amendments and updating with the new management changes so that resident have accurate details regarding services. Although activity programmes have been reviewed there are still restrictions upon community based activities mainly because the home’s mini-bus is no longer working. Residents complained that they were not going out as much as they would like. This was echoed by staff. Records demonstrated that there has been a reduction in residents’ outings and community activities. Policies and procedures regarding adult protection require expansion in order to offer greater protection to residents. Not all parts of the premises present as a comfortable and homely environment. Although communal areas are decorated and furnished to an The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 7 acceptable standard, this does not extend to residents’ bedrooms. These are slowly undergoing refurbishment however the quality is variable with some still requiring finishing touches to bring them up to an acceptable level. Bedroom furniture and furnishings are also showing signs of age, wear and tear. There was an Immediate Requirement issued due to the poor condition of some mattresses which residents confirmed were uncomfortable to sleep on. 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 Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 Residents are provided with good information regarding the services available, however further amendments are necessary in order them to be able to make informed choices and have up to date information. EVIDENCE: Although there is a comprehensive statement of purpose and service user guide, there has been a long standing requirement to add further details in order to fully comply with the Care Homes Regulations and National Minimum Standards. The recent changes in ownership and management also need to be reflected in the amended documents. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Some care plans and risk assessments require expansion as they do not cover all aspects of personal and social, and health care; this could have the potential to place service users at risk. Service users are able to make decisions about their lives however improvements are needed in care planning to demonstrate how individual choices have been made. EVIDENCE: Good improvements have been made in care planning and risk assessments since the last inspection. All care plans and risk assessments are being reviewed and updated; it is acknowledged that this will take time to complete in order to make this a meaningful exercise. Some care plans and risk assessments were more advanced than others in stages of progress. For example one resident had a comprehensive care plan including a very detailed behavioural management programme. Antecedent behavioural consequence (ABC) charts are now being consistently completed as previously required. Another service user did not have a completed care plan in place; for example there were no goals identified with regard to personal support, nutrition, social activities, health care etc. A risk assessment was in place regarding challenging behaviour however a corresponding care plan has yet to be The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 11 devised. On the whole case files are much improved and as a result are clearer and therefore are more useful as tools for staff and residents. As with care plans, good efforts have also been made in improvement risk assessments and management. There is a folder containing risk assessments which cover a large number of subjects including service users’ individual activities (a copy of which is also held in their care plan as is good practice) and environmental risks. Some case files contained comprehensive risk assessments whilst others are still in the developmental stages. For example, one service user’s risk assessment refers to ‘inappropriate’ behaviour but does not go on to specify how this manifests itself. There is one service user who requires a wheelchair for long distances however there is no risk assessment in place for this equipment. New risks which have been identified by the Medicines and Healthcare Products Regulatory Agency in January and April 2005 need to be considered and included in risk assessment management. All service users can make their preferences known and are self advocating. As previously identified a person centred planning approach needs to be incorporated into care planning system. Restrictions upon service users’ rights to make decisions have been negotiated and outcomes included in case files. For example, with regard to staff opening mail, cross gender personal care and financial decision making. Service users manage their own finances without the support of any appointees. Care plans need to contain goals and objectives with regard to money management and give explicit guidelines as to how staff support individual residents. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17 Residents take part in appropriate daily activities in order to encourage personal development however, social inclusion has been restricted and as a result service users are not always able to enjoy social stimulation and follow their own hobbies and interests. Staff support service users to maintain family links thereby enriching their lives. Service users’ rights are respected with regard to their daily routines. The home provides a varied and well balanced diet; service users enjoy their meals and meal times. EVIDENCE: In the past there has been a strong emphasis on service users carrying out daily chores and housework, as well as spending one day a week on ‘daily living skills’. It was pleasing to see that attempts are being made to change this culture although during interviews some residents still claim that their favourite activity is a housework task. When asked about their favourite hobby one resident stated “I like cooking and washing up”. Staff report that less time is now spent in the kitchen preparing foods although as yet new activity programmes reflecting changes have yet to be fully implemented. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 13 All residents attend some form of day care or college placement. During interviews they were happy to talk about their day centres and were looking forward to restarting these in September 2005. At the last inspection it was identified that social activities and community based outings had become somewhat reduced. A sessional worker was no longer employed to undertake social activities. As a compromise one of the support workers had been allocated extra hours to take on this responsibility. However, during interviews with both staff and residents it became evident that this is not taking place mainly due to the lack of transport. Residents commented on not going out as much as they did previously. One resident stated “I would like to go out more, but can’t because I have to go out with all of the rest of them”. Another commented “I would like to go out more again. I prefer sporting activities such as swimming and bowling. At the last inspection it was requested that activity programmes were reviewed and expanded in consultation with service users. It was pleasing to see that progress is being made although some programmes have still yet to be fully completed. There is also an improved activity programme monitoring system. Unfortunately, activity programmes which are in place are not being followed. For example, one service user’s programme identifies a weekly swimming session as well as a community based ‘outside’ activity. Neither are taking place. During July 2005 there had only been one recorded outing to a local pub. Service users are no longer involved in weekly food shopping trips. Staff report that problems have been incurred with transport as the mini-bus is no longer road worthy; and staffing shortages due to holidays, have all had an impact upon this aspect of care. Staff fully support residents to maintain their family links. Service users confirmed that they looked forward to visits from their family members and went to their former homes on a regular basis. Daily routines promote independence. For example residents have keys to their own bedrooms. During interviews residents confirmed that they could go to bed when they wished and get up at a time of their own choosing. One resident stated “I like Saturdays, we don’t have to get up too early and have a nice breakfast”. Residents confirmed that staff respected their privacy and knocked on their bedroom doors before entering. One resident discussed how they liked to fetch their own daily newspaper. Two mealtimes were observed. These were very congenial with residents able to stay at the dining table for as long as they wished. Staff are to be commended in their efforts at ensuring mealtimes are pleasurable. They were constantly overheard asking residents if they had had enough to eat. Residents assisted with making drinks and laying the table. The meals were attractively presented and smelt appetizing. It was pleasing to see that The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 14 smaller appetites are catered for by presenting meals on different sized plates. After the evening dinner one resident stated “I did enjoy that”. Residents confirmed that they had plenty of choices and could always ask for an alternative to the main menu if they wished. As requested there are now clear records to demonstrate how residents participate in menu planning as is good practice. Examination of menus reveal a balanced and varied diet with evidence that on occasions residents have opted for alternative choices. The dining room has been re-arranged and residents can now all sit together to enjoy their meal. Records are kept of residents’ alternative food choices to the main menu however as discussed, consideration should be given to keeping more detailed records for monitoring purposes. Due to the lack of transport, the main food supplies are now ordered over the internet. Staff report that this is also an attempt to enable them to spend more time with service users. Although service users do fetch small items of shopping they should also have the opportunity to take part in the weekly and larger food shopping if they so wish as during discussions they stated that they liked this activity. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis; slight improvements are necessary (mainly in care planning/monitoring), in order to further promote good health care practice. EVIDENCE: There are now clearer recording systems for health care appointments. All residents receive regular ophthalmic, dental and chiropody checks. There are nutritional screening and assessments in place. It is pleasing to see that residents are encouraged to take responsibility for their own health care and medication. Clear risk assessments are in place with regard to self administration of medication and one resident also takes responsibility for their own blood sugar monitoring with support from staff if needed. A comprehensive care plan regarding all aspects of diabetic care is still required on behalf of one resident. A care plan needs to be established with details of potential complications with skin care, feet, eyes, diet and high blood pressure. The type and frequency of monitoring from other professionals such as doctors and the diabetic nurse also requires inclusion. Guidelines must be included for staff with regard to hyperglycaemia and hypoglycaemia. There were details of blood sugar monitoring and what constitutes normal levels and this also needs to be added to the care plan. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 16 Although service users have been shown videos to raise their awareness with regard to self examination in order to detect potential complications from testicular and breast cancer, a formal procedure still needs to be established in the care plans with regard to this aspect of their care and other monitoring strategies such as attendance at well person clinics and staff observations during personal care tasks. One resident has fluctuating weight. Staff discussed their concerns and it was pleasing to see that advice from the doctor had been sought demonstrating good monitoring and a proactive approach. Although residents are normally weighed on a monthly basis, there were two months where this resident’s weight had not been recorded. Due to concerns this must be done on a consistent basis. Case tracking revealed some progress with regard to medication practice. For example, the medication policy is currently being expanded and variable doses of medication are now recorded. There were a couple of new items identified during the evaluation of progress towards outstanding requirements as detailed in the Requirements section of this report. As it has now been confirmed as to who is an accredited trainer in the safe handling of medication; the home must pursue training for staff. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Policies and procedures require improvement in order to offer service users more safeguards from abuse. EVIDENCE: The deputy manager stated that the manager is currently reviewing a number of policies and procedures however these were not available for inspection. As previously identified the adult protection policy requires expansion to cover in sufficient detail the new guidelines with regard to the Protection of Vulnerable Adults (POVA) scheme. The deputy could not confirm whether a copy of these guidelines had yet been obtained. It was pleasing to see that there is a copy of the Local Authority vulnerable adult abuse procedures on the premises. On inspection the Whistle Blowing policy also requires amendment. Details must be inserted of the owner with whom contact can be made, as well as the management within the home. The policy should also make clear that abuse of the procedure (staff making false allegations), will result in disciplinary action. The majority of staff still require training in vulnerable adult abuse awareness. Irrespective of this, staff during interviews still gave competent and correct responses as to what constitutes abuse and how they would deal with any allegations or incidents. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 The standard of décor and furnishings with in the home is variable. Communal areas are decorated and furnished to a satisfactory standard but this is not consistent with individual private space. Although this does not pose a risk to service users it does not create a pleasing or comfortable environment. The home is very clean with good infection control practice. EVIDENCE: Since the last inspection there has been an outstanding requirement to establish a written programme of internal refurbishment and forward to the Commission for Social Care Inspection. This has not been forthcoming. All areas were inspected including individual bedrooms with the consent of service users, some of whom showed the inspector their room. The communal areas are furnished to a reasonable standard however some improvements are necessary with regard to stained or worn carpeting. It was pleasing to see that a larger dining table has been purchased so that residents can eat together however 3 of the dining chairs where plastic ‘office’ type chairs and need to be replaced with more suitable furniture. Although there is evidence of refurbishment with bedrooms currently in the process of redecoration, those that have been completed require finishing The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 19 touches to bring them up to an acceptable standard. For example, plasterwork on walls is still cracked, there are areas where plaster is worn but has not been filled-in before repainting resulting in uneven walls, the window frame needs sanding and wood treated before painting. Added to this there is an eclectic range of bedroom furniture some of which is outdated and some which shows signs of wear and tear. A serious concern was identified with regard to a number of mattresses which were found to be worn, lumpy and with springs protruding which made lying down very uncomfortable. A service user who was interviewed confirmed that they found their bed uncomfortable to lie on. Despite this it was pleasing to see that residents had been encouraged to individualize their own bedrooms with personal possessions, hi-fi and television equipment, pictures, photographs and ornaments. They also confirmed that they had chosen their own colours for redecoration. All areas of the premises were found to be clean and tidy. Since the last inspection the laundry has been redecorated and walls made impermeable. There are now laundry procedures displayed. The small laundry contains a hand wash basis and a supply of personal protective clothing, liquid soap and paper towels. The washing machine does not have a sluice cycle but does have a pre-wash cycle if required. This meets the current needs of the service user group. Any additional items discussed during this inspection are contained within the Requirements section of this report. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 35 Service users are supported by competent and qualified staff. Induction and foundation training for new staff needs to be established in order to provide staff with specialist knowledge regarding residents’ needs. EVIDENCE: The home is exceeding the national minimum standards with regard to ensuring that at least 50 of the staff group are qualified to NVQ II or above by 2005 which is commendable. Specialist training is an on-going process, for example some staff have undertaken training in challenging behaviour. Further specialist training is required such as awareness training in diabetes, epilepsy and autism. Staff who were interviewed demonstrated a good knowledge of residents’ needs and preferences. An induction and foundation training programme which is completed within the first six weeks and first six months of employment, and which is provided by an accredited learning disability awards framework trainer, still needs to be accessed. It was pleasing to see that there is an up to date central staff training and development plan now in place. Not all staff have an individual training and development plan in place. Training in equal opportunities and disability awareness is still required. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 21 A number of staffing records and details could not be accessed at this inspection. Items relating to these aspects will therefore remain outstanding as identified in the Requirements section of this report. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41 and 42 Record keeping requires improvement in order to offer greater protection of service users’ rights. There is good health and safety practice although further improvements are necessary in order to fully promote the wellbeing of service users and staff. EVIDENCE: As already stated a number of documents were not accessible in order to undertake a full evaluation of record keeping. However, there were some areas which were identified as requiring improvement. For example, sensitive records such as medication administration record (MAR) sheets and records of residents’ food choices from the menu were unsecured in the dining room. Service users’ care plans are currently being developed and as yet do not contain all of the information required by the Care Homes Regulations 2001. All maintenance and service checks were examined and were found to be up to date with only a couple of exceptions. There was evidence that all portable electrical appliances had received an annual check and fixed wiring electrical The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 23 installation has received an inspection within the last five years. All fire equipment had been inspected during the last twelve months as well as the fire alarm and emergency lighting system. Staff are not always testing the fire alarm on a weekly basis; there was only one check in May 205 and two checks in June 2005. Although the last month had seen an improvement. Emergency lighting is not being tested on a monthly basis. Staff admit there is some confusion over the length of testing and advice should be sought from the fire service and manufacturer. Although fire evacuation drills are carried out on a regular basis, records of staff names who participate in the drill are not always being recorded. Names should be recorded in order to establish that all staff participate in a bi-annual fire safety drill. There is regular testing of water temperatures. The Legionella risk assessment has now been expanded in liaison with the home’s plumber however there is no mention of bacterial analysis or chlorination. Given that the alterations have recently been made to the water system (a thermostatic control has been fitted to the kitchen sink as a health and safety measure), this now requires chlorination. The home received an inspection from an Environmental health and safety officer in February 2005. A report has been submitted with a small number of requirements. Good progress is being made towards addressing items identified. Statutory training for staff is an on-going process. Staff have now completed training in first aid awareness and food hygiene. Fire training however needs to be given more priority as only four staff have up to date fire safety training. Four staff completed this training last year (which is now out of date) and two staff have yet to receive training. All staff must undertake this training on a bi-annual basis. On the whole there is good food hygiene practice. For example, there is regular testing of cooked food, fridge and freezer temperatures. All foods are labelled with the date of opening or freezing, and no foods were found to be out of date. Some minor improvements are necessary. For example, following a shopping trip that morning, staff had placed the pork chops for the evening meal on the window sill instead of in the fridge. The upright freezer in the conservatory is rusty in areas and seals require cleaning. It was discussed with management that the service provider is not supplying the Commission for Social Care Inspection with a report of a monthly visit undertaken in compliance with the Care Homes Regulations 2001, Regulation 26. There were no copies of reports on the premises for the last three months. Any additional items regarding these standards discussed during this inspection are contained within the Requirements section of the report. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x 2 Standard No 11 12 13 14 15 16 17 3 2 2 2 3 x 2 Standard No 31 32 33 34 35 36 Score x 2 x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Limes Score x 2 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5 Requirement Timescale for action 1/11/05 2. 6 15 To amend Statement of Purpose and Service User Guide to ensure it accurately reflects service provision and complies with current Standards and Regulations (to forward to the Commission for Social Care Inspection). (Previous timescale of 1/1/04 is not met). A written plan, which details how 1/12/05 all their care needs are to be met by the home, must be produced for each service user. To include all aspects of care and with clearly stated goals and objectives with timescales for monitoring. (Previous timescale of 1/1/04 is partly met). 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. (Previous timescale of 1/6/05 is partly met). To introduce a person centred planning process to assist The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 26 3. 7 17(2) 4. 9 13(4)(c) 5. 10 12(4)(a) service users with developing their care plans. Where any restrictions are made on a service user’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, opening of residents’ mail and cross gender personal care. (Previous timescale of 1/1/04 is partly met). Individual risk-taking assessments must be undertaken on all service users and regularly reviewed, i.e. with regard to challenging behaviour, wheelchair users etc. (Previous timescale of 1/1/04 is partly met). To establish a detailed policy regarding Confidentiality including a statement on confidentiality to partner agencies. (Previous timescale of 1/1/04 is partly met). 1/12/05 1/11/05 1/12/05 6. 12 16(2)(n) 7. 13 16(2)(m) To produce written procedures regarding service users access to their own records. To distribute these to service users with documented evidence kept that this has been carried out. (Previous timescale of 1/1/04 is not met). To undertake a review of 1/11/05 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). (Previous timescale of 1/6/05 is partly met). To provide more opportunities 1/11/05 for all service users with regard to social inclusion. To ensure all Version 1.40 Page 27 The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc service users are facilitated to participate in the community in accordance with preferences and assessed needs. To carry out a documented review of the transport provided by the Home to ensure that it meets the needs of all service users. Alternative options must be accessed if transport is not suitable. To ensure records are maintained of service users’ individual food choices from the daily menu. (Previous timescale of 1/6/05 is partly met). To introduce a procedure for the monitoring of service users’ health with regard to potential complications such as breast screening, testicular screening etc. (Previous timescale of 1/1/04 is partly met). To establish a care plan for a service user who is diabetic to include all aspects of diabetic care including: skin, eyes, foot and dietary care, potential complications and monitoring by specialists. (Previous timescale of 1/10/04 is not met). To ensure that there is more consistent monthly checking and recording of service users weight. To improve the control and administration of medication: 1) Medication policy/procedures must be reviewed and include details of all aspects of the safe handling of medication. (Previous timescale of 1/11/03 is The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 28 8. 17 16(2)(i) 1/11/05 9. 19 12(1)(a) 1/11/05 10. 20 13(2) 1/11/05 partly met). 2) To arrange for all staff to undertake accredited training in the safe handling of medication. (Previous timescale of 1/11/03 is not met). 3) To undertake monitoring and recording of the temperature of the drugs cupboard which is currently located in the kitchen area to ensure that this does not exceed 25 C. (Previous timescale of 1/6/05 is not met). 4) To undertake a written risk assessment with regard to a member of staff who currently administers medication but has not provided a certificate to confirm appropriate training has been undertaken. (Records not accessible therefore not assessed at this visit). 5) To ensure that all medication received into the home is fully recorded. 6) To ensure that two staff initials are obtained to confirm any changes made to computerized instructions on Medication Administration Record (MAR) sheets. 7) To ensure that medication administration record (MAR) sheets are accurately completed with no gaps. The home must review its Adult Protection policy/procedure to ensure compliance with the Department of Health Guidance and associated legislation (this must include procedures regarding the new Protection of 11. 23 13(6) 1/12/05 The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 29 Vulnerable Adults (POVA) scheme. (Previous timescale of 1/1/04 is partly met). To obtain a copy of the Department of Health guidance on the Protection of Vulnerable Adults Scheme (POVA). (Previous timescale of 1/5/05 is not met). To provide all staff with training in vulnerable adult abuse. (Previous timescale of 1/4/04 is not met). To review and expand the Whistle Blowing policy to include contact names and numbers for senior management and to cover false allegations and misuse of the policy. To undertake the following improvements to the environment: To carry out an audit of the premises and establish a written programme of maintenance and refurbishment. To forward a copy to the CSCI together with timescales for completion of works identified. (Previous timescale of 1/5/05 is not met). 1) To clean or replace stained and/or worn carpets in communal areas and individual bedrooms. 2) To repair cracked plasterwork in individual service users bedrooms. 3) To progress plans to replace worn flooring in the first floor shower room. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 30 12. 24 23(2)(b) 1/12/05 4) To replace worn mirror in first floor shower room. 5) To replace 3 plastic chairs with more appropriate and comfortable dining chairs. 6) To carry out a written audit of all worn mattresses and establish a programme of replacement together with timescales for completion. To forward to the Commission for Social Care Inspection by 30 August 2005. - IMMEDIATE REQUIREMENT. 7) To investigate and repair creaking floorboards in service users bedroom. 8) To repair worn flooring in service users ensuite toilet. 9) To replace all worn/torn net curtains. 10) To repair worn window frame in service users bedroom. 11) To ensure all wardrobes are securely fixed to bedroom walls. 12) To replace stained grouting around service users wash hand basin. 13) To replace all worn bedroom furniture. 14) To carry out a written risk assessment with regard to the use of multiple electrical adaptors. 15) To repair cracked overhead light in service users ensuite toilet. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 31 16) To replace worn kitchen units. 17) To repair broken extractor cooker hood. 13. 30 13(3) To ensure COSHH information is held and displayed in the laundry. (Previous timescale of 1/6/04 is not met). Job descriptions must be reviewed and linked to the home’s Statement of Purpose and the individual needs of the service users. - (Unable to access records to establish progress). All staff must be provided with a copy of the General Social Care Council standards of conduct and practice. (Unable to access records to establish progress). To provide specialist training for all staff in: 1) Autism awareness. (Previous timescale of 1/4/04 is not met). 2) Diabetes awareness. (Previous timescale of 1/4/04 is not met). 3) Epilepsy awareness. (Previous timescale of 1/4/04 is not met). 4) Understanding challenging behaviour. (Previous timescale of 1/6/05 is partly met). To ensure that a copy of the Staffing Guidance from the Department of Health (DoH) is 1/12/05 14. 31 18(1)(a) New Date: 1/12/05 To be reported on at the next inspection) 15. 32 18(1)(c) 1/12/05 16. 33 18(1)(a) 1/11/05 The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 32 17. 35 18(1)(c) obtained and the formula applied, taking account of the assessed identified needs of the residents, with the results forwarded to the NCSC and Social Services Commissioning Section for consideration; together with staffing rotas, which clearly identify care hours, ancillary hours and details of hours service users spend at funded day care. (Previous timescale of 1/1/04 is not met). Staff must be provided with a structured induction and foundation training programme that is provided by a Learning Disability Awards Framework registered provider. (Previous timescale of 1/1/04 is not met). To provide staff with training in equal opportunities and disability equality. (Previous timescale of 1/4/04 is not met). To establish individual training and development assessment profiles for all members of staff. (Previous timescale of 1/1/04 is not met). The manager must develop and implement a planned programme of individual staff supervision. (Unable to access records to establish progress). To ensure that the manager is qualified to NVQ IV in care and management by 2005. Effective quality assurance systems must be developed by the home. (Unable to access records to establish progress). Policies and procedures must be 1/11/05 18. 36 18(2)(a) New date: 1/12/05 to be reported on at next inspection. 31/12/05 New date: 1/12/05 to be reported on at next inspection. 1/12/05 Page 33 19. 20. 37 39 18(1)(c) 24 21. 40 24 The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 22. 41 19(1)(b) 17(2) reviewed regularly using current professional guidelines and legislation. (See Appendix 3 of the National Minimum Standards for Younger Adults). (Previous timescale of 1/8/04 is partly met). All appropriate documentation, required to be obtained on staff under Schedule 2 of the Care Homes Regulations 2001, must be obtained and kept available for inspection on the premises. (Unable to access records to establish progress). To ensure that there is a complete case file in place for every service user containing all documentation identified in Regulation 17,Schedule 3. (Unable to access records to establish progress). To ensure that all confidential and senstive records are held secure in compliance with the Data Protection Act 1998. To provide training for all staff commensurate with their duties which include: 1) Moving and handling. (Previous timescale of 1/1/04 is partly met). 2) Health and Safety. (Previous timescale of 1/1/04 is partly met). 3) Infection control. (Previous timescale of 1/1/04 is not met). 4) To ensure that all staff receive bi-annual fire safety training. (Previous timescale of 1/6/05 is not met). To improve health and safety New date: 1/12/05 to be reported on at next inspection. 23. 42 18(1)(c) 1/12/05 24. 42 13(4)(c) 1/11/05 Page 34 The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 practice: To carry out a written Legionella risk assessment. (Previous timescale of 1/1/04 is partly met). To carry out written risk assessment for all Control of Substances Hazardous to Health (COSHH) products which are used. (Previous timescale of 1/11/04 is partly met). To undertake weekly testing and recording of the fire alarm system and monthly testing of the emergency lighting system. (Previous timescale of 1/5/04 is not met). To undertake chlorination and bacterial analysis of the water system. To make the following improvements to food hygiene practice: 1) To review and expand written food hazard analysis (HACCAP). (Previous timescale of 1/5/04 is partly met). 2) To ensure that fresh meat products are stored at refrigerated temperatures prior to cooking. 3) To replace or repair upright freezer which has become rusty in places. 4) To thoroughly clean and remove mould from seal on upright freezer. 5) To defrost and repair broken drawers on small freezer located The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 35 25. 42 13(4)(c) 1/11/05 in the kitchen. 6) To comply with all of the requirements identified by the environmental officer - in report dated 3 March 2005. 26. 43 26 To ensure that copies of the monthly reports from visits undertaken by the Owner (or representative) are available on the premises and a copy forwarded to the Commission for Social Care Inspection. 1/11/05 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. 3. 4. 5. Refer to Standard 18 22 24 42 Good Practice Recommendations To consider introducing a key worker system. To consider producing the complaints system in a pictorial format. To consult with service users with regard to the location of the water dispensor which is currently sited in the communal lounge. To record the names of staff who participate in fire evacuation drills. The Limes E55_V239248_The Limes_S63539_240805_Stg4.doc Version 1.40 Page 36 Commission for Social Care Inspection Halesowen Local Office Mucklow Office Park, West Point Mucklow Hill Halesowen, West Midlands National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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