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Inspection on 01/11/05 for 262 Tunnel Lane

Also see our care home review for 262 Tunnel Lane for more information

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 29 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Tenants go out of the home to take part in leisure activities in their local community on a regular basis. There are sufficient staff on duty to facilitate the tenants` needs and offer them a choice of activities during the day. The staff are working with City College and the tenants to help them to personally develop and to experience new opportunities. The home has an accessible vehicle and there are drivers available to facilitate the tenants to go out on a regular basis if they chose. The staff support the tenants to take part in many household tasks, including cleaning, ironing and making snacks. The staff support the tenants where possible to maintain regular contact with their friends and family. The home supports one tenant to access an Advocacy Service and one tenant to access a befriending service. Staff have visited twice daily the tenant who has been in hospital since August and have supported their relative to visit them.

What has improved since the last inspection?

The majority of the issues highlighted in the last inspection have not been fully achieved. The complaints procedure is now in accessible format. The Speech & Language Therapist supports tenants, with their communication needs, to fully understand their rights under the complaints procedure. The home now has no staffing vacancies and has appointed an Acting Team Leader for the next six months. Having more staff has enabled the tenants to be supported more and to have a choice of activities to do in the day. Two tenants have been on holiday and one tenant was on holiday at the time of the inspection. There are plans to support the two other tenants to go out on a series of day trips of their choice, as these tenants would rather do this than go on holiday. The increased permanent staffing levels provide stability to the service and will support the staff to undertake the issues outstanding from this and the previous inspection.

What the care home could do better:

Personal profiles, care plans, risk assessments and health notes still, require completing fully for each tenant as a matter of priority. This remains outstanding from the last inspection. The service user guide and tenants contracts detailing their terms and conditions, highlighted as a requirement in the last inspection need to be completed. The staff have been offered the opportunity to read the Protection of Vulnerable Adults Policy the organisation has, however staff are required to attend a training day in this respect, to ensure the staff are fully aware of how to protect the tenants from harm. Food hygiene training still needs to be undertaken for the majority of the staff team. The staff training files need updating, to accurately reflect the training staff have undertaken, with copies of their certificates being available on the premises. All fire points in the home must be checked weekly and emergency lighting monthly to make sure they are working.Water temperatures although checked weekly must reflect the action taken when temperatures are regularly over the safe recommended level of 43 degrees centigrade. The annual testing of all portable electrical appliances is overdue and this needs to be completed as soon as possible. The recording of the controlled medication in the home needs to improve, to ensure accurate recording, including correct date order, and consistency in the number of checks undertaken per day. Regular and recorded supervision of staff needs to take place at least six times a year, with at least annual appraisals of staff performance. More attention should be paid to the accurate recording of amounts of money spent in tenants personal finance records, so it can be clearly seen how much money was spent. The lounge and the downstairs hall carpets need replacing as cleaning has failed to remove the obvious stains. The sofas in lounge are obviously old and worn and need replacing. The tenants bedrooms need redecorating, and the tiling around the sink of the tenants bedroom on the ground floor needs to be undertaken, to prevent further damage to the walls from sink unit. The kitchen refurbishment is still to be undertaken and the Acting Team Leader advises this has been scheduled for February 06. The bathrooms and toilets on the ground and first floor still require redecoration and pedal bins need to be purchased for all bathrooms. The toilet seat in the downstairs shower room needs replacing as it is chipped and cracked. Whilst some evidence was found in the two tenants file sampled, of regular weight checks, better recording needs to take place, so a visual record can be easily seen of the tenants weight, to promote the tenants good health and wellbeing. Minutes of regular meetings with tenants and staff meetings about tenants should be kept, demonstrating discussions have taken place about how choices and decisions were made affecting the tenants lives. Clear, accurate and easily accessible health information regarding appointments and outcomes for tenants must be available in the tenants` records, to enable staff to properly meet the identified health needs of the tenants.Tunnel Lane, 262DS0000016797.V262722.R01.S.docVersion 5.0Page 8

CARE HOME ADULTS 18-65 Tunnel Lane, 262 Kings Heath Birmingham West Midlands B14 6JX Lead Inspector Sarah Bennett Unannounced Inspection 1st November 2005 10:00 Tunnel Lane, 262 DS0000016797.V262722.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 Tunnel Lane, 262 DS0000016797.V262722.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. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tunnel Lane, 262 Address Kings Heath Birmingham West Midlands B14 6JX 0121 443 4131 0121 443 4131 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) FCH Housing & Care Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 20th June 2005 Brief Description of the Service: 262 Tunnel Lane, is located in Kings Heath, Birmingham. The home is set within an established residential area. It is not recognisable as a care home, but blends in with ordinary domestic houses. The home briefly comprises of the following, on the ground floor there is a kitchen, open plan dining room and lounge, a bathroom with walk in shower, a toilet and laundry room. There is one bedroom on the ground floor, the other four bedrooms are located on the first floor. There are two additional bathrooms with WCs. The staff sleep-in room is a combined office. To the rear of the home there is a large garden, which has ramped access and raised flowerbeds. The home has a combined lounge and dining room. There is no space for tenants to meet in private, other than their own bedrooms. There is no alternative room for tenants who smoke. An extractor fan is provided in the dining room, which is used by tenants who smoke. However, tenants are encouraged to smoke in the garden when possible. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook an unannounced inspection over five hours. The information was collected in a number of ways, including a tour of the premises, looking at two tenants files, medication records, staff training records, Policies and Procedures, Health and Safety records, three staff files and talking with a tenant and staff on duty that day. The Operations Manager visited the home during the inspection. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from June 2005. The inspectors would like to thank the people who live in the home and the staff on duty who supported the inspectors on their visit. What the service does well: What has improved since the last inspection? Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 6 The majority of the issues highlighted in the last inspection have not been fully achieved. The complaints procedure is now in accessible format. The Speech & Language Therapist supports tenants, with their communication needs, to fully understand their rights under the complaints procedure. The home now has no staffing vacancies and has appointed an Acting Team Leader for the next six months. Having more staff has enabled the tenants to be supported more and to have a choice of activities to do in the day. Two tenants have been on holiday and one tenant was on holiday at the time of the inspection. There are plans to support the two other tenants to go out on a series of day trips of their choice, as these tenants would rather do this than go on holiday. The increased permanent staffing levels provide stability to the service and will support the staff to undertake the issues outstanding from this and the previous inspection. What they could do better: Personal profiles, care plans, risk assessments and health notes still, require completing fully for each tenant as a matter of priority. This remains outstanding from the last inspection. The service user guide and tenants contracts detailing their terms and conditions, highlighted as a requirement in the last inspection need to be completed. The staff have been offered the opportunity to read the Protection of Vulnerable Adults Policy the organisation has, however staff are required to attend a training day in this respect, to ensure the staff are fully aware of how to protect the tenants from harm. Food hygiene training still needs to be undertaken for the majority of the staff team. The staff training files need updating, to accurately reflect the training staff have undertaken, with copies of their certificates being available on the premises. All fire points in the home must be checked weekly and emergency lighting monthly to make sure they are working. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 7 Water temperatures although checked weekly must reflect the action taken when temperatures are regularly over the safe recommended level of 43 degrees centigrade. The annual testing of all portable electrical appliances is overdue and this needs to be completed as soon as possible. The recording of the controlled medication in the home needs to improve, to ensure accurate recording, including correct date order, and consistency in the number of checks undertaken per day. Regular and recorded supervision of staff needs to take place at least six times a year, with at least annual appraisals of staff performance. More attention should be paid to the accurate recording of amounts of money spent in tenants personal finance records, so it can be clearly seen how much money was spent. The lounge and the downstairs hall carpets need replacing as cleaning has failed to remove the obvious stains. The sofas in lounge are obviously old and worn and need replacing. The tenants bedrooms need redecorating, and the tiling around the sink of the tenants bedroom on the ground floor needs to be undertaken, to prevent further damage to the walls from sink unit. The kitchen refurbishment is still to be undertaken and the Acting Team Leader advises this has been scheduled for February 06. The bathrooms and toilets on the ground and first floor still require redecoration and pedal bins need to be purchased for all bathrooms. The toilet seat in the downstairs shower room needs replacing as it is chipped and cracked. Whilst some evidence was found in the two tenants file sampled, of regular weight checks, better recording needs to take place, so a visual record can be easily seen of the tenants weight, to promote the tenants good health and wellbeing. Minutes of regular meetings with tenants and staff meetings about tenants should be kept, demonstrating discussions have taken place about how choices and decisions were made affecting the tenants lives. Clear, accurate and easily accessible health information regarding appointments and outcomes for tenants must be available in the tenants’ records, to enable staff to properly meet the identified health needs of the tenants. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 8 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. Tunnel Lane, 262 DS0000016797.V262722.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 Tunnel Lane, 262 DS0000016797.V262722.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): 1&5 Prospective tenants do not have the information they need to make an informed choice about where to live. Tenants do not have individual contracts so are not aware of the terms and conditions of their stay at the home. EVIDENCE: At the last inspection staff could not find the service users guide. The Acting Team Leader said that this has not been completed but will be developed soon. The Statement of Purpose was seen at the last inspection and included all the relevant and required information. The current tenants have lived at the home for a number of years. The assessment process for prospective tenants has not been assessed in this inspection year. The Operations Manager said that she is trying to track all the tenants’ contract’s from the time the tenants moved into the home. When these have been found these will be included in the service users guide. Tunnel Lane, 262 DS0000016797.V262722.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, 7, 8, 9 & 10 The systems in place, still do not adequately inform staff of the tenants individual needs which could lead to individuals needs being consistently unmet. Tenants are involved and consulted with on what happens in the home. Substantial work needs to be undertaken to identify all potential risks for and to tenants, from this more risk assessments must be identified and completed for individual tenants. Confidential information about the tenants was appropriately handled within the home. EVIDENCE: All the tenant’s records were in the process of being updated. In two of the files sampled, some work had been undertaken to fully update the personal profiles of the tenants. However, this was confusing to follow, as there were several files in operation for the two service users, with information held in Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 12 different places. On one of the tenants files, risks were identified, but they were not followed on with risk assessments in the files. On one of the files sampled there were not adequate risk assessments in place, to support the tenant with his epilepsy and the updated personal profile did not make reference to his epilepsy. Generally, throughout the files sampled, there needed to be better crossreferencing; in the support guidelines, care plans, personal profiles and risk assessments. Of the two files sampled, there was evidence of at least six monthly review dates, some of which had been signed as completed. However, no evidence could be found of notes from these reviews or changes that had taken place to risk assessments following the review. In one of the tenants files there was evidence of support given to the tenant via the advocacy service. Two of the tenants take part in regular meetings FCH tenant meetings, where they are supported and encouraged to take part in what goes on in FCH and their individual homes. The Operations Manager said they were in the process of working with the tenants to get their informed consent to make the minutes of these meetings available, demonstrating tenant involvement and action taken from these meetings. The Acting Team Leader said there are regular meetings in which the staff discuss the needs of those tenants who are unable to participate in the tenant meetings to look at how best to meet their individual needs. The team meeting minutes demonstrated full discussions about issues affecting the home and the how to meet the care and health needs of the tenants. Tenants individual meetings minutes, detailing how decisions were arrived at, were not available at the time of the inspection. There are also regular meetings involving other professionals, to look at how best to meet tenants needs, including the Community Nurse, Speech and Language Therapist, Psychiatry, the Dietician and GP. This was reflected to some extent in the tenants files sampled. On one of the files sampled there was evidence of a multidisciplinary approach to signing of risk assessments. However, it was not apparent, from the two tenants files sampled that decisions made from multidisciplinary meetings, were included or informing the tenants care plans and risk assessments. On the day of the inspection the confidential records pertaining to the tenants were securely kept, indicating good practice on behalf of staff handling of tenants confidential information. No inappropriate communication between Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 13 staff about tenants was observed. All observed staff interaction with tenants appeared positive and respectful. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 16 Arrangements are in place so that people living in the home experience a meaningful lifestyle. EVIDENCE: Tenants do not have day centre placements, staff at the home provide the day care. Staff supported one tenant to go out for lunch with a relative. Two staff supported another tenant to go to Solihull for lunch on the bus. One of the tenants is able to go out on their own and said they liked to do this. However, the following day they had requested to go out with a member of staff on the tram to Wolverhampton. One tenant has been in hospital since August. Staff said that they are visiting them twice daily to offer support and are also supporting their relative to visit. One of the other tenants has recently been supported to visit them. Records of opportunities for tenants to take part in activities had recently been started. Few of these had been completed. The Acting Team Leader said these are to be discussed at a staff meeting so that all staff will be aware. One tenant was on holiday at Butlins, Skegness supported by two staff. Staff supported another tenant to go on holiday to Devon for a week earlier in the Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 15 year. The tenant showed the inspector photographs of the holiday and said that they had enjoyed it. The Acting Team Leader said that some tenants prefer to go on day trips than holidays and these are being regularly provided for these tenants. Tenants have recently started taking part in the City College Programme. This enables tenants to develop their skills in household tasks and leisure activities within the community. Tenants records sampled showed staff support tenants to go shopping, use public transport and to go to the bank. Tunnel Lane, 262 DS0000016797.V262722.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, 20 & 21 It remains unclear how each tenant is supported with their personal care, emotional and health needs. The arrangements for the management of the medication within the home protects the tenants. It is unclear what tenants wishes are in regard to their ageing, illness and death. EVIDENCE: The home is in the process of putting in place full personal profiles and health notes for all tenants detailing their preferences on how they like to receive personal support. In the two tenants files sampled this was only partially completed, with health records and information not completed for either tenant. Tenant files sampled demonstrated guidelines and protocols on the management of challenges the tenants present. There was evidence on one tenants file of a proactive strategy. Staff were observed to follow these plans Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 17 to divert and distract a tenant from a situation that was making him feel anxious. The team meeting minutes demonstrated full discussions about issues affecting the home and the how to meet the care and health needs of the tenants. Staff are in the process of putting in place full personal profiles and health notes for all tenants detailing their preferences on how they like to receive personal support. In the tenants files sampled this was only partially completed, with health records and information not completed for either tenant. One of the tenants’ records indicated that they had not been weighed since April 2005. In order to ensure tenants well being they should be weighed monthly and a record of this kept. The Acting Team Leader said that, now that there is a full staffing complement, they hope to start work on Health Action Plans with the Community Nurse, and undertake training for the staff team in Person Centred Planning, which would then lead to individual Person Centred Plans. The files sampled demonstrated involvement from other health professionals including, the dietician, community nurse, psychiatrist, GP, optician, hospital outpatient appointments and the speech therapist. Of the two tenants files sampled, the advice and support given by these professionals must be included/referenced more, to underpin the guidance in the care plans and risk assessments. Two of the tenants had epilepsy. There were clear guidelines in place to support the tenants with their needs. This information was kept with the tenants’ medication files; however, it was not referenced in either tenants file, as to where to find this information. Signed protocols were in place for individuals, signed by the family, a staff member, the community nurse and GP. Where appropriate ‘rescue medication’ was available for these tenants. There was a clear procedure in place for the checking and safe storage of this medication. However, more attention needs to be given to the accurate recording of the controlled medication checks, to include a consistent number of daily checks made by the staff, ideally at each staff handover and accurate date recording. Medication is stored in a locked cabinet, with a separate locked cabinet in place to store the controlled medication. Two staff check the controlled medication at least twice a day. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 18 Boots supply the medication via a monitored dosage system; there was evidence of an audit by the Boots pharmacist in May of this year. Creams used must be dated when opened and discarded after 28 days. Medication administration records cross-referenced with the monitored dosage system, indicating that medication had been given as prescribed. Of the two tenants PRN medication sampled, the PRN medication administered cross referenced accurately with the signatures on the prescription chart, indicating medication was given as prescribed. PRN protocols were present on the medication files. Evidence was found in one of the tenants file, about the need to discuss the ageing process, illness and meeting the wishes of the tenant in the event of their death. There was no evidence of this discussion having taken place with the tenant in the file. The Acting Team leader said a lot of this work had been undertaken via discussions with parents and the community nurse for this tenant. The Acting Team Leader said this work had also been undertaken with the tenant and the family of the tenant who is currently in hospital; this was done in conjunction with the community nurse. The records of this tenant were not sampled on the day of the inspection. Staff have regularly supported this tenant and their family during their stay in hospital. Tunnel Lane, 262 DS0000016797.V262722.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 & 23 The arrangements for making complaints are adequate to ensure tenants views are listened to and acted on. Adequate arrangements are not in place to protect tenants from abuse. EVIDENCE: Since the last inspection the complaints procedure has been put into an accessible format for the tenants to understand. The Speech and language Therapist has been working with the tenants to ensure that they understand their rights under the complaints procedure. Staff have not received training in adult protection and the prevention of abuse. This remains outstanding from the previous inspection. The Operations Manager said that this training has been planned for all staff to receive. The Acting Team Leader said that all staff have received a copy of the Adult Protection procedure to read. Two tenants financial records were examined. Each tenant has their own bank account that their benefits are paid into. Each tenant has a financial risk assessment and support plan. Receipts are kept of all purchases and these cross-reference to the amounts spent on individual’s financial records. One of the tenants financial records recorded they had spent 60 on two occasions in one week. There was no indication of what this was spent on and it was unclear whether this was £60 or 60p. The Acting Team Leader said that it was 60p and showed receipts to verify the expenditure. Tunnel Lane, 262 DS0000016797.V262722.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): 24, 26, 27, 28 & 30 The condition of the decoration and furnishings does not enable tenants to live in a homely and comfortable environment. Tenants bedrooms need redecorating so that they suit their needs and reflect their interest and lifestyles. The shared space in the home is not adequate to complement and supplement individual rooms. EVIDENCE: The sofas in the lounge are covered with throws. Underneath these the sofas look faded and old, these need to be replaced with new sofas. The lounge carpet had been cleaned recently, however this had not been able to remove the many stains on the carpet, the carpet in this room needs replacing. The carpet in the hall immediately outside the lounge is also heavily stained and requires cleaning and if this fails to remove the marks, replacing. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 21 The lounge is pleasantly decorated in neutral colours and had a number of photographs around the room of the tenants. There was also a number of items on shelves and tables around the lounge reflecting individual tenants interests. The kitchen area still requires refurbishment, as identified on the last inspection; the Acting Team Leader said this work is scheduled for February 2006. The requirement to decorate the tenant’s bedrooms remains outstanding; the Acting Team Leader said this work was planned for the early part of next year. One of the tenants rooms had recently been decorated, however further tiling work was required around the sink area to prevent water affecting and damaging the surrounding wall. The tenants bedroom contained many pictures which they said were of interest to them. There were also photographs displayed in their bedroom. All the bathrooms and toilets are in need of redecoration, there were hand towels and soap dispensers observed in each toilet and bathroom. The arrangements in the bathrooms and toilets were adequate to provide sufficient privacy and meet the needs of the tenants. The toilet seat in the shower room on the ground floor must be replaced, as the seat is very worn, showing signs of cracks and chips. Pedal bins need to be purchased for all the bathrooms and toilets to support the management of cross infection within the home. The home has adequate washing and laundry facilities, with hand washing facilities available in this area. The staff were observed to be storing the COSHH substances appropriately and a COSHH file further supported this, with data sheets on the products used in the home. The garden area has ramped access and benefits from being a large open space, with a patio and patio furniture. There is also a large shed that one of the tenants uses to store some of his belongings in. One of the tenants is undertaking a college course and is supported to work in the garden and has a small vegetable patch, growing runner beans and pumpkins. More effective use of storage space needs to be considered, to prevent keeping filing cabinets in the hallways, and to look at an alternative area/work space immediately outside the lift. The Operations Manager said that this was an issue in a number of the FCH homes and that this situation was being looked into. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 22 The home was generally clean, tidy and free from any offensive odours, although more attention could be given to the cleaning of certain areas, like window ledges and work surfaces in the kitchen. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35 & 36 Staffing levels are adequate so that tenants are supported by an effective staff team. Tenants are protected by the home’s recruitment practices. Arrangements for supporting and developing staff are not adequate and could affect their ability to meet individual tenants needs. EVIDENCE: The Acting Team Leader said that there are no staffing vacancies. Three support workers have started working at the home since July 2005. Tenants have at least 1:1 support from staff during the waking day, some tenants have 2:1 staff support particularly when going out in the community. Staff meetings take place at least six times a year. There was an agenda for the meeting held in September. However, there were no minutes available of this meeting. Four staff records were sampled, three of the staff had started working at the home during 2005. Some records included proof of identity. Records included evidence that Criminal Records Bureau checks had been undertaken. The Operations Manager said that all the required staff recruitment records were held in a separate filing cabinet in the home. However, another manager who had been providing support to the home currently had the key to this filing cabinet. The Operations Manager said that the key would be made available to the Acting Team Leader. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 24 Training records for staff who had recently started working at the home contained little evidence that they had completed any training. The other member of staff records sampled showed that they had received training in epilepsy, autism, health and safety, fire safety, first aid, manual handling and Violence and Aggression. There was no evidence that any of the four staff had received training in food hygiene. However, all staff are involved in food preparation for the tenants. The Operations Manager said that they are putting a place a training file, which should clearly state what training each member of staff has received and what training has been identified that they need. Staff supervision records indicated that one member of staff has had four, formal, recorded supervision sessions in the last year. Of the three newly recruited staff two had received one formal, recorded supervision sessions. One member of staff had received none despite working at the home since July 2005. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39, 42, 43 The home has recently recruited an Acting Team Leader and all staffing vacancies are currently filled, which will support more effective running and management of the home. The arrangements for promoting and protecting the health, safety and welfare of the tenants are not adequate. EVIDENCE: The post of Acting Team Leader had been recruited to, in October 2005. The Acting Team Leader said he hoped to tackle the outstanding requirements from the last inspection and support the staff team with the introduction of a more effective system of recording necessary information. The Acting Team Leader and the Operations Manager felt that they ensured the tenants views were sought, and that these views underpin the running of the home and the review and the development of the home. This was something FCH undertook and viewed as an important part of the work they do with their tenants. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 26 This was supported in a number of ways including tenants meetings, however the current process cannot be demonstrated as a format that comes together to form a quality assurance system undertaken annually. The Operations Manager said this was an issue that FCH were looking to put in place in their homes. These new recording systems will relate to tenants files and H & S checks, there was evidence that some of these pieces of work were beginning to be undertaken. Fire records showed that not all call points were being tested; this needs to happen on alternate weeks, on a weekly basis. Fire drills had taken place six monthly and outcomes from these drills recorded, these had taken place in the summer of this year, on concurrent months. It would be beneficial if there were longer gaps left between the drills, and another one was undertaken shortly to support the new staff in post. Risks clearly identified from the fire drills need to be followed up with risk assessments in tenants’ individual records. Emergency lighting must be checked monthly and recorded as such with any problems recorded along with the actions taken. Water temps are checked weekly; however there must be details of recorded action taken, when these checks demonstrate the water is hotter than the recommended temp of 43 degrees centigrade. Fridge and Freezer temps are being checked every day, but staff must ensure they record the actual temperature, rather than the current practice of ticking the sheet to say it has been completed. The system currently in place does not adequately support the safe practice of storing food. There were certificates in place detailing correct testing of the gas system, the electric hard wiring and the maintenance of the lift. There was also evidence of a maintenance book and the recording of jobs needed, the priority of each job and when they had been completed. The inspectors did not check whether Legionella testing had been completed on the water system. A valid certificate of employers liability insurance was seen. The inspectors were satisfied that there were comprehensive organisational policies and procedures in place, to support accountable management of the service. However, more attention needs to be paid by staff to the effective use of the systems made available to them. In the areas of medication recording, personal finance records, minute taking of meetings, the recording of Health and Safety Checks, completing tenant information packs, signing all signature Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 27 lists pertaining to individual and generic risk assessments, policies and procedures, attending all statutory training that is available via the organisation and specialist training in areas of need pertaining to the tenants who live in the home. Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 1 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 2 2 1 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 1 2 2 x 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 3 1 1 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tunnel Lane, 262 Score 1 1 2 2 Standard No 37 38 39 40 41 42 43 Score x 1 1 x x 2 2 DS0000016797.V262722.R01.S.doc Version 5.0 Page 29 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 2 Standard YA1 YA5 Regulation 5 (1) (af), (2) 5 (1) Requirement A service users guide must be developed. (Previous timescale not met). Each tenant must have a copy of the contract that includes all the required information. (Previous timescale not met). Each tenant must have a care plan that is detailed and specific. (Previous timescale not met). Analysis of health care needs must inform care planning. (Previous timescale not met). Risk assessments must be updated and kept under review. (Previous timescale not met). How the health needs of each tenant will be met must be fully documented. (Previous timescale not met). Each tenants care plan must state how they are to be supported with their personal care. (Previous timescale not met). Each tenant must have a Health Action Plan in line with ‘Valuing People.’ (Previous timescale not met) All tenants must be weighed DS0000016797.V262722.R01.S.doc Timescale for action 31/01/06 31/12/05 3 4 5 6 YA6 YA6 YA9 YA18 Sch3(1)a, b,15(1,2) 12(1) (a), 13 (4) 15 13 (4) (a, b, c) 13 (1) (b) 31/12/05 31/12/05 30/11/05 31/12/05 6 YA18 12 (1) (a), 15 (1) 12(1)(a) 13 (1)(b) 12 (1) (a) 31/12/05 7 YA19 28/02/06 8 YA19 30/11/05 Page 30 Tunnel Lane, 262 Version 5.0 9 10 11 12 13 YA20 YA24 YA24 YA24 YA24 13 (2) 23 (2) (d) 23 (2) (d) 23 (2) (b, c) 23 (2) (b, c) 23 (2) (b, d) 23 (2) (b, d) 23 (2) (b, d) 16(2)(j) 23(2)(b) 23(2) (m) 16 (2) (j, k) 13 (6), 18(1) (a, c) 18 (1) (a, c) 18 (2) monthly and a record of this kept. (Previous timescale not met). The recording of the controlled medication in the home must improve. The lounge carpet must be replaced. The ground floor hall carpet must be replaced where cleaning has failed to remove the stains. The kitchen units must be replaced. The sofas in the lounge must be replaced. Tenants bedrooms must be redecorated. Tiling around the sink of the tenant’s bedroom on the ground floor must be undertaken. The bathrooms and toilets must be redecorated. The toilet seat in the downstairs shower room must be replaced. Extra storage space must be provided. Lidded bins must be provided in all bathrooms and toilets. All staff must receive training in adult protection. (Previous timescale not met). All staff must receive training in food hygiene. (Previous timescales not met). All staff must receive regular and recorded supervision sessions at least six times a year. 01/11/05 31/01/06 28/02/06 31/03/06 30/04/06 14 15 YA26 YA26 31/03/06 30/11/05 16 17 18 19 20 21 22 YA27 YA27 YA28 YA30 YA35YA23 YA35 YA36 28/02/06 30/11/05 30/04/06 30/11/05 31/03/06 31/03/06 31/12/05 23 YA39 24(1)a,b (2)(3) 24 YA42 A formal quality assurance system must be in place that considers tenants and their relatives’ views. 23(4)a,c,v The emergency lighting must be DS0000016797.V262722.R01.S.doc 31/03/06 02/11/05 Page 31 Tunnel Lane, 262 Version 5.0 Sch4(14) 25 26 YA42 YA42 23(4)a,c (v)Sch4 14 13 (4) (a, b, c) Elec At WorkRegs tested monthly and a record of this kept. The fire alarm must be tested weekly and a record of this kept. Appropriate action must be taken to ensure that water temperatures are maintained at 43 degrees centigrade. All portable electrical appliances must be tested annually. 01/11/05 04/11/05 27 YA42 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. 1 Refer to Standard YA8 Good Practice Recommendations Minutes of regular meetings with tenants and staff meetings about tenants should be kept, demonstrating discussions have taken place about how choices and decisions were made affecting the tenants lives. Details of discussions with tenants about their ageing, illness and death should be recorded. More attention should be paid to the accurate recording of amounts of money spent in tenants personal finance records, so it can be clearly seen how much money was spent. Minutes of all staff meetings should be kept. Each member of staff should have an annual appraisal. 2 3 YA21 YA23 4 5 YA33 YA36 Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tunnel Lane, 262 DS0000016797.V262722.R01.S.doc Version 5.0 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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