Inspection on 01/11/05 for The Willows

This inspection was carried out on 1st November 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 no outstanding requirements from the previous inspection report, but made 36 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Willows 09/09/08

The Willows 18/09/07

The Willows 24/05/06

The Willows 18/05/05

The Willows 20/01/05

The Willows 22/07/04

The Willows 18/11/03

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 Willows, The 1 Park Road Hockley Birmingham B18 5JH Lead Inspector Donna Ahern Announced Inspection 1st November 2005 10:00 Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 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 Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 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. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Willows, The Address 1 Park Road Hockley Birmingham B18 5JH 0121 554 1427 0121 523 6073 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) Social Care and Health Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Currently residing people who are over 65 may continue to be accommodated provided their needs can be met appropriately. The minimum staffing level for 18 service users on weekends when daycare is off site are: 7.00am - 9.00am 4 care assistants, 1 of whom is designated shift leader 9.00am - 4.00pm 3 care assistants, 1 of whom is designated shift leader 4.00pm - 10.00pm 5 care assistants, 1 of whom is designated shift leader 10.00pm - 7.00am 2 care assistants both awake At weekends and periods without off-site daycare 09.00am - 10.00pm 5 care assistants, 1 of whom is designated shift leader 10.00pm - 07.00am 2 care assistants, both awake 07.00am - 09.00am 4 care assistants That the home is registered to accommodate 15 adults under the age of 65 in need of long-term personal care for reasons of learning disability. Areas of worn internal paintwork must be repainted by end June 2004. Windows where paint is flaking away from the frame require repair by end June 2004. Bedroom 13 requires repair by end of June 2004 An experienced, suitably qualified and competent manager to be recruited and an application for registration is made to the CSCI by end of June 2004 By end of September 2004 plans are agreed with the NCSC/CSCI with stated timescales for the future re-provision of this service to ensure standards commensurate with fitness for purpose for the needs of the client group. May 2005 3. 4. 5. 6. 7. 8. Date of last inspection Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 5 Brief Description of the Service: The Willows is a large two- storey purpose built home providing care and accommodation for up to 15 adults with learning disabilities. The range of needs of individuals living at the home is diverse and some of the residents have complex additional needs. The home is owned and staffed by Birmingham Social Care and Health. The home is situated on the corner of a busy street in the middle of Hockley. The Willows is central to a selection of bus routes and other amenities such as shops, pubs, leisure facilities and various places of worship. To the front of the building there is a large area used for off street parking and minibus drop offs. Disabled access to the building is variable. The home has a shaft lift and adapted toilet and bathing facilities. All residents’ rooms are single. The home has four lounges/quiet rooms for the use of residents. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and involved two inspectors. It took place over one long day. The inspectors met all residents and time was spent observing care practices, interactions and support from staff. A tour of the building was made. Residents care plans and risk assessments were inspected. Staff training and recruitment procedures were examined, and a number of Health and Safety records were inspected. The inspectors spoke to the deputy manager, two assistant managers and five support workers. An expert by experience Stephen, and his support worker Becky from Sandwell People First were involved in part of the inspection. As a service user Stephen had an expert opinion on what it is like to receive services for people who have a Learning Disability. Comments and observations of the expert by experience and CSCI inspectors are referred to in the report as the “inspection team”. What the service does well: What has improved since the last inspection? There was evidence of improvements in the homes record keeping since the previous inspection. Records were well organised in the main staff office and information was easy to find. The CSCI pharmacy inspector undertook a full audit of the homes medication procedures. The systems for medicine management have improved since the last inspection. Clear comprehensive arrangements had been installed to ensure resident’s medication needs are met. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 7 What they could do better: It has been a difficult time with changes in the management of the home and the temporary manager was off sick when the inspection took place. There was a need for significant development of resident’s documentation so that resident’s needs and changing needs are kept under review and a consistent plan is in place for the staff to follow. The home must improve the care plans that they have developed for each resident. These must tell the staff how to support each person. They must be clear about what help and support each resident needs and what staff must do to support the individual. These must be kept up to date. The home must improve how it says it will help residents reduce some of the risks that they may face in the home or when they go out on an activity. The staff must improve the way that resident’s health needs are recorded monitored and followed up. There must be guidelines in place for staff to follow so that they know how best to support each resident with their health care and when to seek further medical help. The home must start to do Health Action Plans with each individual. They must also keep up to date the support that residents need with their mobility. The staff and managers must look at how they can promote resident’s wellbeing and independence and enable residents to do more things for themselves like cooking and domestic jobs in the house. This must happen on a regular basis and not just on rare occasions so that residents can really develop their skills and have more involvement in daily living. A lot of work was required to the building to make it a comfortable and safe place for residents. Many of the bedrooms need decorating; painting of the woodwork and windows was needed. Some of the tiles in the bathroom were in need of repair. The home must make sure that the bathrooms are suitable for all the residents and that they can safely get in and out of the bath. The Provider must let the people living in the home and CSCI know what the plans are for the future of this home. The Provider must action the matters of concern raised in the West Midland Fire report. This was of serious concern and resident’s safety must be promoted and protected. The Work Place Fire Risk assessment required updating to include the shortfalls and must be kept under review. Staff must do more training so that they have up to date knowledge and skills regarding the residents they support. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 8 The required information on staff who work in the home must be available (such as their previous experience and training) and evidence that all of the safety checks on their suitability to work in the home have been carried out before they start to work at the home. So that the provider can demonstrate their commitment to protect residents. It will be good for residents and the development of the home when there is a permanent manager in place. 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. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed at this inspection. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Care plans required development so that a comprehensive plan is in place for each residents that details how their assessed needs and goals will be met. Risk assessments must be developed so that residents are supported to take risks within a risk assessment framework. EVIDENCE: Four care plans were sampled. Individual Service Statements (I.S.S) were on file and there was evidence that these had been reviewed. The I.S.S document was not sufficient as a care and support plan for residents. There was evidence that information on the I.S.S was frequently repeated. Information was not in sufficient detail regarding how best to support each resident and how their assessed needs were to be met. It was unclear how recommendations from other professionals are implemented into the present care plan format. The inspection team spoke to some of the residents about their care plans. Residents said that they were unsure if they had a care plan or not. The inspection team felt that residents should be aware of their care plan. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 12 They should be fully involved in writing plans about themselves and have it written in a format the person understands. This could be words, pictures or in sound. Residents spoken to indicated that they did not have a Person Centred Plan either. The inspection team felt that it was essential that people have these plans in place to find out what they want to do with their life. Social Care and Health senior managers have informed CSCI that they were in the process of reviewing their care plan documentation and looking at supporting residents to complete plans that are person centred. CSCI will monitor progress on this at the next inspection. The assistant managers said that guidelines and behaviour management plans had been reviewed. It was not possible to evidence this. The guidelines on the sampled file were dated 2003. The recently revised guidelines could not been found. Files had recently been archived and it was thought that the information might have been filed in error. This information must be available on file for staff to follow. A number of risk assessments were sampled. Further development was required. Risk assessments must be reviewed following any accidents or incidents to ensure that that the control measures in place are adequate. The support required by residents from care staff during the night must be risk assessed and any support required from staff must be clearly documented. Some risk assessments that had been implemented on residents who access the community independently required additional information. Risk assessments required implementing in other areas that may pose a risk to residents. It was essential that these were implemented. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15,16 and 17 Residents were supported to take part in activities at home and in the community. The staff must improve opportunities and be able to evidence how they support residents to develop their independent living skills. EVIDENCE: Care plans required development to evidence how residents are provided with opportunities to develop their social, communication and independent living skills. Residents said that they sometimes use the small kitchen on the first floor to prepare snacks and their supper but not on a regular basis. They said that they sometimes do clothes washing and use the main laundry. The domestic washing machine on the first floor was still broken this was raised as a requirement at the inspection in May 2005. As raised in the previous inspection report improvement to how the manager and staff offer opportunities for residents to develop their independence and life skills is still required. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 14 Many of the residents attend local day centres Monday to Friday. Some of the residents do not attend any formal day care. The inspection team spoke to some of the residents. They said they would like to do more around the home, but because there is a cook and cleaner the opportunity was taken away. The main kitchen is an industrial kitchen, which is staffed by commercial services staff, which is part of the City Council. Residents were not allowed to use this kitchen. An area had been developed in the dining room so that residents can make their own drinks during the day. Since the previous inspection a fridge had been installed. As raised previously this facility could be developed so that residents could make their own snacks. Drinks were observed being served from a trolley to residents at midmorning. It was unclear why residents were not supported to make their own drinks. One of the residents told the inspection team that they keep very busy and they loved going to college, going shopping and spending time with their key worker. Some of the other residents did not seem to do a lot in the day although staff did explain that two of the residents were not very well. In the evenings people seem to go out a lot together. They recently went to Blackpool for the day and the Walsall illuminations and on the night of the inspection people were going out to a club, and a meal out at a local pub had been arranged for another evening. The inspection team felt that it was good to hear that people have an active life in the evening but wondered how often people get a choice to go out in smaller groups or individually. Residents chatted to the inspection team about their family and friends. One resident said they were going to see their parents soon and will be staying with them for a week another resident said “I see my family on the weekends and I like it when they visit”. Another resident said that their friend visits her every week and they enjoy spending time together. They said, “ Staff make my friend feel welcome”. The inspection team felt that people were encouraged to keep contact with their families and friends. Three questionnaires were received from relatives who made positive comments about the staff. One relative said, “I have nothing but praise for the staff”. Residents can use a payphone, which was located in the smoking room. The room was very smoky. The inspection team thought it was unfair on people who want to use the phone and do not smoke and that there was a lack of privacy for people when they do use the phone. Residents told the inspection team that they do not go food shopping, the food is delivered. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 15 They have a cook who prepares the food for lunch and dinner and they have a choice of two different meals. Some of the residents said that they would love to do these tasks. The inspection team felt that the structure of the home denies residents the opportunity to develop basic skills. One of the residents said that they used to live in a more independent living environment and since moving to the home had lost these skills. One of the inspectors observed the evening meal, which seemed quite early and was well underway at 16.50. The food served looked really nice and everyone seemed to have something different. Residents spoken to said they liked the food. Some of the residents cleared away their own plates. Staff did not sit with residents but were present to support when required. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Improvements must be made to resident’s health care information so that the manager and staff can demonstrate that residents have received the medical and health input they require. Clear guidelines and monitoring systems must be in place so that staff know when and how they must refer on to appropriate specialists. Manual handling assessments had not been kept under review and had the potential to place residents at risk. EVIDENCE: Many of the residents have lived at the home for a long time. As they become older some of the residents have experienced health problems and changes in needs and mobility. Care plans must be developed so that they include resident’s preferences about personal care and how this should be delivered. Manual handling risk assessments assessed had not been kept under review and had not reflected the changes in resident’s mobility. They had not been reviewed when an accident or incident had occurred. There was a contradiction on one residents file regarding the frequency of night checks they have and this required clarification. Information on resident’s files must be consistent Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 17 There was information on file identifying the specific health needs of residents. There was insufficient detail on how the staff should support the residents to manage the specific health matter. One example of this was a resident who is diabetic. There were no guidelines in place for staff to follow regarding signs of illness, acceptable blood sugar levels and circumstances where medical treatment must be sought. This was an outstanding requirement and it was of concern that this remained outstanding. Two of the residents files assessed indicated that there were issues around resident’s food intake. There were no guidelines in place for staff to monitor their food and when and what further action may be required. The foot and nail care of one resident was discussed with the assistant manager. Inspectors were informed that there was chiropody input but this had to be done very gradually at the resident’s own pace. It was of concern that their toenails had been allowed to deteriorate to such a poor condition. There was no evidence of the chiropody treatment to date and the work undertaken to manage the person’s tolerance. There were shortfalls in the recording of general health care appointments and the outcomes of appointments. It is essential that resident’s health is monitored and potential complications and problems identified and dealt with at an early stage. Including prompt referral to an appropriate specialist. The specific health needs of two residents were discussed with the assistant managers including what seemed to be potential delays in residents receiving prompt G.P input. The assistant managers explained the difficulties in getting a Doctors appointment when required and that they often have to wait up to a week for an appointment. If this is the case the staff must clearly document this and if needed seek further advice. Individual risk assessments and guidelines were required for the residents who have epilepsy. The assistant manager explained that the epilepsy liaison nurse was in the process of working with the staff and advising on the risk assessments. These must be actioned and were raised at the previous inspection. Some progress had been made on the implementation of Health Action Plans. People who have input from community Nurses were being supported to complete these. The staff had started the process with some of the other people by supporting them to attend well person check. Progress on these will be monitored closely at the next inspection. The systems for medicine management have improved since the last inspection. Clear comprehensive arrangements had been installed to ensure resident’s medication needs are met. All audits undertaken were correct indicating that the medicines had been administered as prescribed. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 18 All prescriptions were seen prior to dispensing and photocopied and the dispensed medication checked against these upon receipt. Consultant letters or new prescriptions supported all dose changes. The pharmacist dispensed medication separately for the service user to take to the day centre, which is commended. All Controlled Drug balances were correct and mirrored the balances on the Medicine Administration Record (MAR) chart. The home is to install a new medication cabinet, which was commended. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Development of the Complaints and Adult protection policies were required so that the manager can demonstrate that individuals are listened to and concerns fully investigated. EVIDENCE: The previous inspection required that some minor additions were required to the Adult Protection Policy and Procedure, so that there is clear information and relevant contact details for staff to access and follow in the event of abuse being suspected or disclosed. This remained outstanding. The complaint log was assessed. The outcome of the initial investigation for three complaints had not been completed and four complaints had not been processed through the organisations complaints system. The inspection team spoke to residents about what they would do if they were unhappy about anything. People spoken to said they could go to the managers. The inspection team thought it was good that residents felt able to talk to staff but also thought it would be good if residents were more aware of other places they can complain to and thought that people could work on a poster which could be displayed in the home to let people know who else they can complain to other than staff in the home. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is not suitable for the purpose of achieving its stated aims and objectives. Many parts of the home required redecoration and were not well maintained and comfortable for residents. EVIDENCE: The building does not meet the National Minimum Standards for Younger Adults. A condition of the homes registration was that by the end of September 2004 plans would be forwarded to CSCI for the future reprovision of this service to ensure standards commensurate with fitness for purpose and for the needs of the client group. As previously reported these timescales had long passed. CSCI met formally with the provider in September 2005. An action plan was forwarded to CSCI, which stated that the provider would forward a planned maintenance programme and a redevelopment plan for all Learning Disabilities homes by 21/11/05. A number of routine repairs and maintenance matters remained outstanding. The assistant managers provided evidence of written requests, which had been sent to the providers maintenance department requesting that the work was completed. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 21 A summary of the matters that required attention was as follows. The door to the ground floor assisted bathroom required repair it wouldn’t fully close. Damp in corridor, in bedroom 13, in large lounge, in spare bedroom and on the wall by the lift. Window latches required repairing in a number of rooms including bedrooms and the laundry. Lock on wardrobe doors required repair room 3 and 9. The detergents in the laundry room required boxing in. Tiles required repair and upstairs bathroom tiling required completion. Door handles required repair in room 2, 16 and 10. Vanity light required repair room 13 and 9. Extractor fan required repair sleep in room and bathroom. Holes in wall required repair. Paintwork and decoration required attention in several areas of the home. The intermittent door seals had been painted over. Tiles in ground floor bathroom required repair. First floor shower room bath mat required replacing and ceiling decorated and shower pipe replacing. Window grills loose and broken (small bathroom). Light fittings required cleaning as full of dead insects. Drink area in the dining room required cleaning. West Midland Fire Service undertook an inspection of the premises in April 2005 Fire Safety arrangements were considered unsatisfactory and contravening the Fire Regulations. A number of matters requiring attention was raised in the report and were still outstanding. This was of serious concern. An immediate requirement was left for CSCI to receive an action plan regarding these concerns action to be taken and proposed timescales. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staffing levels required review so that adequate staff are on duty to meet resident’s needs and to meet the staffing conditions of registration. Information held in the home on Staff and recruitment practices are not adequate and fail to demonstrate that the home was safeguarding residents. Staff required training updates so that they have the required skills and knowledge to meet resident’s needs. EVIDENCE: Staffing levels are a condition of registration. The following level of staffing is required. 07.00hrs- 09.00hrs 4 care staff on duty, one of which must be a designated shift leader. 09.00hrs- 16.00hrs 3 care staff on duty, one of which must be a designated shift leader 16.00hrs- 22.00hrs 5 care staff on duty, one of which must be a designated shift leader 22.00hrs- 7.00am 2 care staff on duty, both on a waking night shift. At weekends between 09.00hrs and 22.00hrs there should be 5 care staff on duty one of which must be a senior. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 23 Sampling of the rota identified there was a shortfall on some evening shifts after 20.00hrs. The provider must ensure that minimum staffing levels are maintained as detailed above. Sampled staff files did not contain all the required information that would demonstrate that a thorough recruitment process was in place. The home must have the required information on each staff member who is employed at the home, as detailed in schedule 2 of the National Minimum Standards for Younger Adults. Attention was required to the frequency of formal supervision of staff. Sampled records indicated that sessions take place on an infrequent basis. Staff must receive a minimum of six supervisions a year so that they receive the support and supervision they need to carry out their job. Training on Challenging Behaviour, Diabetes, First Aid and Adult Protection remained outstanding and must be actioned for all staff. Training In Fire Safety matters were scheduled to take place on the 14/11/05. The inspection team spoke to residents about how they get on with staff. Some residents made very positive comments. One resident said,” I love spending time with my key worker ”. Some residents said they do not get on with all staff and some of the staff shout. One resident said that they don’t tell anyone they just get on with it. Some of the other residents said they have told the managers about staff who shout or are rude. The inspection team felt that residents shouldn’t have to get on with it and it is totally unacceptable for residents to be shouted at. The assistant manager spoken to at the time of the inspection said that concerns from residents are listened to and dealt with. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,42 and 43 Development of Health and Safety practices and record keeping was required to ensure that resident’s welfare and safety is protected. EVIDENCE: The manager’s post at the Willows had been vacant for a protracted period. An acting manager has been in post and had transferred on a temporary basis from another Social Care and Health home. At the time of the inspection the acting manager was on long term sick. The Recruitment process for a permanent manager was in the final stages. The proposed manager has an interview with CSCI in November 2005. There was evidence of improvements in the homes record keeping since the previous inspection. Records were well organised in the main staff office and information was easy to find. Throughout the inspection process the assistant managers presented as open, positive and inclusive. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 25 A number of Health and Safety records were examined and were generally in good order with evidence of regular tests and servicing taking place. The work place Fire Risk assessment required some amendments the outstanding work to the homes fire safety measures must be highlighted in the assessment and kept under review as the work is completed. The matters identified in the West Midland Fire Safety report of April 2005 see standard 24, were largely outstanding and were of serious concern. CSCI must be kept fully informed of the provider’s actions to put right the contraventions of the Fire regulations. The homes monitoring of accidents required some further development. The monitoring form had not been completed since July 2005. Managers and staff must revisit risk assessments to review the control measures following an incident, accident or a near miss. Risk assessments regarding residents, their health care records and residents care plans required further development so that the provider can evidence that their needs and changing needs are kept under review. Where the provider is an organisation they are required to nominate someone to carry out unannounced visits to the home and carry out interviews with residents, their representatives and persons working at the home. A written report on the conduct of the home must be produced and a copy available at the home for inspection and a copy sent to CSCI. Examination of the reports available in the home indicated that such visits had not been undertaken since March 2005. The owner’s representative must evidence that such visits have been undertaken in accordance with the regulations, and that they are fulfilling their responsibility to oversee the overall management of the home. Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 26 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 X X X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X 2 2 X X 2 LIFESTYLES Standard No Score 11 1 12 2 13 2 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 2 2 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Willows, The Score 1 1 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 1 DS0000033630.V255974.R01.S.doc Version 5.0 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 12 (1) (5) Requirement Care plans required further development.They must be clear and specific about the support required by residents and kept under review. (Previous requirement 30/3/05). Guidelines and Behaviour management plans must be kept under review. (Previous requirement 30/6/05) Residents profiles must be updated and kept under review.(Previous requirement 31/8/05) Risk assessments must be further developed. They must be clear and specific about what the risk is and the support required by care staff. They must be kept under review. The review must be comprehensive. (Previous requirement 31/8/05) The Provider must provide opportunities for residents to develop their independent living skills. (Previous requirement 30/6/05) The provider must develop the drink facilities available to residents. (Previous requirement DS0000033630.V255974.R01.S.doc Timescale for action 28/02/06 2 YA6 12 (1) (a, b) 15 (1) (2) 30/11/05 3 YA6 31/12/05 4 YA9 13 (4) (a, b c) 31/12/05 5 YA11 12 (1) (a, b) 31/01/06 6 YA11 16 (2,g, h) 31/12/05 Willows, The Version 5.0 Page 28 30/6/05). 7 YA18 13 (5) Residents Manual handling risk assessments required further development. They must be kept under review. (Previous requirement 30/6/05) Residents support during the night must be risk assessed.(Previous requirement 30/6/05) Risk assessments and support guidelines for residents with epilepsy must be implemented. (Previous requirement 30/6/05) The home must improve residents healthcare recording and monitoring. (Previous requirement 30/6/05) Guidelines were required for the resident who has diabetes to ensure that staff are aware of the action to be take in the event of a high/low blood sugar level.(Previous requirement 30/1/05). Health Action Plans must be implemented for all residents.(Previous requirement 30/9/05) Guidelines must be in place to support residents with specific health problems. Outstanding complaints must be fully actioned. Minor development of the Adult protection procedure was required. (Previous requirement 31/7/05). Redevelopment plans for the service must be forwarded to CSCI. (Previous requirement September 2004) A planned maintenance and renewal Programme for the building was required. The door to the ground floor assisted bathroom required DS0000033630.V255974.R01.S.doc 01/12/05 8 YA18 13(4)(a, b, c) 12 (1) 31/12/05 9 YA19 14/11/05 10 YA19 12 (1) (a) 14/11/05 11 YA19 12(1)(a) 13(4)c 14/11/05 12 YA19 12 (1) (a) 31/01/06 13 14 15 YA19 YA22 YA23 12(1)(2) 13(1)(a b) 22 13 (6) 30/11/05 30/11/05 31/12/05 16 YA24 23(1)(a) (2)(a) 23(2)(a & b) 23(2)(b) 21/11/05 17 18 YA24 YA24 21/11/05 01/12/05 Willows, The Version 5.0 Page 29 19 YA24 20 21 22 YA24 YA24 YA24 23 YA24 24 25 YA24 YA24 26 YA24 27 YA24 28 YA26 29 YA27 30 YA30 repair. Damp in corridor, in bedroom 13, in large lounge, in spare bedroom required repair. 23(2)(b) The Window latches required repairing in a number of rooms including bedrooms and the laundry. 23(2)(b) The Lock on wardrobe doors required repair room 3 and 9. 13(4) The detergents in the laundry room required boxing in. 23(2)(b) Lock on wardrobe doors required repair room 3 and 9. Door handles required repair in room 2, 16 and 10. 23(2)(b&d) Tiles required repair and upstairs bathroom tiling required completion. Window grills were loose and broken (small bathroom). 23(2)(b) Extractor fan required repair sleep in room and bathroom. 23(2)(b&d) Holes in the wall required repair. Paintwork and decoration required attention in several areas of the home. 23(2)(b&d) First floor shower room bath mat required replacing and the ceiling decorated and shower pipe required replacing. 23(4)(a-e) The outstanding matter raised in the West Midland Fire Service report of April 2005 required attention. CSCI must be kept informed of progress. 16(2)(c) All bedrooms must be audited against the National Minimum Standards for Younger Adults . Any shortfalls must be provided. (Previous timescale 15/3/05) 23(2)(n) An occupational Therapy Assessment is required regarding the suitability of the present bathrooms.(Previous requirement 31/8/05) 23(2)(c) The washing machine on the first floor that residents can use DS0000033630.V255974.R01.S.doc 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 14/11/05 31/12/05 31/12/05 30/11/05 Page 30 Willows, The Version 5.0 required repair. 31 YA34 7,9,19 Sch 2 The home must have on each staff file all of the information as detailed in schedule 2 of the National Minimum Standards for Younger Adults. Staff must receive training in Challenging Behaviour. Adult Protection. First Aid Diabetes. (Previous timescale 30/4/05) Atraining plan and matrix was required. Staff must receive regular supervision at least six per year with records kept. The work place Fire Risk assessment required review. Accidents to residents must be audited. A representative from Social care and Health must visit the home unannounced on a monthly basis. Reports of the visits must be available in the home. Copies of the report must be forwarded to CSCI. (Previous requirement 15/3/05) 31/01/06 32 YA35 18(1)(a,c) 31/01/06 33 34 35 36 YA36 YA42 YA42 YA43 18(2) 23(4)13 (4) 17 (1) a Sch 3 (j) 26 31/01/06 30/11/05 30/11/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willows, The DS0000033630.V255974.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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