Inspection on 15/10/07 for Ulysses House

This inspection was carried out on 15th October 2007.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ulysses House 25/04/08

Ulysses House 19/04/07

Ulysses House 10/10/06

Ulysses House 04/05/06

Ulysses House 12/10/05

Ulysses House 27/04/05

Ulysses House 13/01/05

Ulysses House 01/09/04

Ulysses House 07/02/04

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 Ulysses House 28 Fountain Road Edgbaston Birmingham West Midlands B17 8NR Lead Inspector Sarah Bennett Key Unannounced Inspection 15th October 2007 09:25 Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ulysses House Address 28 Fountain Road Edgbaston Birmingham West Midlands B17 8NR 0121 429 9555 0121 429 9777 ulysses653@aol.com 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) Ulysses Care Limited Vacant post Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 19th April 2007 Brief Description of the Service: Ulysses House offers accommodation for up to six young adults with learning disabilities who present with challenging behaviour. Ulysses House is a large, three storey, semi-detached Victorian house. The home is located in a residential area in Edgbaston and is well served by public transport. It is within walking distance of local shops, pubs and restaurants and the centre of Bearwood and is a short bus ride from the centre of Birmingham. Each person living there has their own bedroom, two of which have en suite facilities. The home has a large dining room and kitchen, comfortable sitting room and utility room/laundry. The staff sleeping in room is also used as the office. There is a bathroom on the first floor and a WC on the ground and first floor. The premises can accommodate fully mobile adults, and does not offer disabled access or adaptations. There is a large enclosed garden to the rear of the house offering a large patio area and a lawned area. The CSCI inspection report is available in the home for visitors to read if they wish to. The service users guide did not state the fees that are charged to live at the home. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out over one day; the home did not know the inspector was going to visit. This was the homes second key inspection for the inspection year 2007 to 2008. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home – Annual Quality Assurance Assessment (AQAA). Two people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The people who live at the home were spoken to. Due to their learning disability and communication needs it was not always possible to get their views on the home. The staff and the Deputy Manager were spoken to. Some of the people living there and staff completed the Commission’s surveys asking for their views of the home. The Commission has had concerns about this home for several years and the safety of the people living there. However, this key inspection has found that several improvements had been made improving the lives of the people who live there. What the service does well: Each person has their own care plan so that staff know how to support them to meet their needs and do the things they want to do. The people living there have an individual health action plan. This is a personal plan about what a person needs to stay healthy. Staff know how to help each person to meet their health needs. Each person has their own bedroom with a number of personal belongings in them. This gives them their personal and private space. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 6 People have the freedom to go out on their own if they want to and are able to. Staff make sure it is as safe as possible for them to do this. One person said, “I have got a bus pass. I go to the bank with staff to get my money.” The people who live there know who their key worker is and said they helped them to do the things they want to do. One person said, “ My key worker is really nice. The new manager visited last week and she was nice.” People said that they are happy living at the home. What has improved since the last inspection? What they could do better: All bedroom doors must be fitted with a lock that can be opened if there is an emergency so that staff can help people to be safe. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 7 Water temperatures must be not be too hot so that people are not at risk of being scalded. The statement of purpose and service users guide should be updated with the relevant information. This will make sure that people have the information they need about the home and the service provided. Staff should keep helping the people living there to eat a healthy diet and tell them how their diet affects their health. Individuals’ should be weighed when needed. This will help make sure that people’s health needs are met. Pharmacists labels should not be covered on individual’s medication as this may lead to people not getting their right medication so their health needs may not be met. All staff should know about of the Mental Capacity Act and what this means for the people living there. The window ledge in the lounge should be replaced and the shower rail in the second floor bathroom should be made safe. The fire officer should be asked how safe it is to use the bolt on the front door. Records should be kept when the fire equipment is tested to make sure it is working. This will make sure that the people living there and staff are able to get out in an emergency. A quality assurance system should be in place. This should consider the views of the people living there so that their views make a difference to the service provided. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have all the information they need so they can make an informed choice about whether or not they want to live there. Arrangements are in place to ensure that individual’s needs are assessed before they move to the home to ensure they can be met there. EVIDENCE: The service users guide to the home was produced using pictures making it easier to understand. It generally included the relevant and required information. However, it included the details of the previous manager so needs to be updated when the new manager is in post. The statement of purpose was last updated in June 2006 and also included the details of the previous manager. This also needs to be updated and include the fees charged. This will give prospective service users the information they need so they can make an informed choice as to whether or not they want to live there. There have been no new people admitted since the last inspection and there were no vacancies. Therefore, the standard relating to assessment could not be fully assessed. However, the admission policy stated that an assessment would be completed before a person moved into the home to ensure that their Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 10 needs could be met there. This would include consulting with the person, their representatives and any professionals involved in their care. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have the information they need in individual’s care plans and risk assessments so they can support the people living there to meet their needs and maintain their safety and well being. The people living are supported to make choices and decisions about their day-to-day lives and what goes on in the home. EVIDENCE: Two records of the people who live there were looked at. These included an individual care plan that stated how staff are to support the person to meet their needs and achieve their goals. The care plan detailed how staff are to support the individual with their personal care, health needs, medication, managing their behaviour, communication, their lifestyle including their social, leisure, personal development and their dietary needs. One person was observed communicating with staff using Makaton (a type of sign language). It was good to see that staff understood what the person was saying and communicated with them using Makaton so helping to ensure they can meet their needs. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 12 Each person living there has an opportunity to meet with their key worker each month and talk about the things they want to do, the menus, their care plan and if it needs updating, setting goals for the next month and how they spend their money. One persons care plan stated that to reduce their anxiety they can have 1:1 time with staff when they request it in addition to their monthly key worker sessions. Meetings are regularly held with the people who live there and minutes of these are kept. Minutes showed that people talked about health and safety issues, staff training, furniture, holidays, menus, the new smoking legislation, person centred planning and decorating their bedrooms. In one meeting they talked about the plans for the garden and asked if they could have a trampoline. It was good to see that this request was soon granted and records showed that people who live there have enjoyed using this. People said that they could choose what things they do, where they go, what they eat and the colours for decorating their bedrooms and communal rooms of the home. Records included individual risk assessments. These stated how staff are to support the person to take risks in their day-to-day lives whilst ensuring their safety and welfare. Risk assessments were detailed, regularly reviewed and updated where the persons’ needs had changed. Staff had signed to say they had read and understood so they can all manage the individual’s risks in a consistent way. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that people living in the home experience a meaningful lifestyle. The people living there are offered a healthy diet but further improvement is needed to ensure that people are informed of how their diet affects their health. EVIDENCE: Two people are doing IT courses at college, one person is doing a cookery course and two people are doing a Makaton (sign language) course. The Deputy Manager said that a tutor from the college was visiting the next day to look at what other courses are available that the people living there could do. One person attends a supported work placement four days a week. They recently attended a presentation day there where they were presented with a certificate for their achievements. A member of staff also attended and supported them. Records sampled showed that people take part in a range of activities inside and outside the home. These include watching TV and DVD’s, going shopping, Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 14 going to the pub, restaurants, bowling, going to the cinema and going for walks. People are encouraged to use public transport including buses, trains and taxis. Staff said that one person goes to church on Sundays but none of the other people who live there have expressed an interest in going to places of worship. Staff said that one person has an Aston Villa season ticket and enjoys going to the home matches with staff. Records stated when people had been offered the opportunity to do activities outside the home but had chosen not to. All the people living there had been on holiday to Blackpool with staff. People said that they enjoyed this and one person had said in their monthly key worker session that they would like to go to Blackpool again. Records sampled showed that people are supported to keep in contact with their family and friends through phone calls, letters, visits from them and visits to them where appropriate. Staff said that the people living there are supported to buy presents and cards for their family and friends for special occasions. A thank you card to the staff was sent by one relative thanking them for helping the person to pick a present for their birthday and that it was a lovely surprise. Staff said that they had an open day recently, which families were invited to and the new manager came to meet people. Photographs had been taken of this. They were on the computer that the people living there use, as a slide show so they could see them and talk about the day, which they had obviously enjoyed. The people living there are encouraged to be as independent as possible and take part in household tasks. These include cleaning their bedrooms, helping to do the cooking and doing their laundry. Two people went out with staff to do the food shopping. When they came back the people living there and staff helped bring the shopping in from the taxi and put it away. Food records sampled showed that a variety of food is offered to individuals. Fresh fruit and vegetables are included in people’s diet. Records sampled showed that some people needed to lose weight so they can be healthy. One of their food records showed that in one week they had been recorded as eating chips three times and in nine days they had eaten chips five times. The recommended amount of fruit and vegetables that people should eat each day to be healthy is five portions. In nine days it had been recorded that the person had between 0 to 4 portions of fruit and vegetables each day. The Deputy Manager said that they had recognised this and the new manager had said that she is planning to work with the dietician to design diet plans for individuals. It is evident that staff are trying to encourage people to have a healthy diet. A variety of fresh fruit and vegetables were available. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are sufficient to ensure that the people living there receive personal support in the way they prefer and require. Generally individual’s health needs are met. The management of the medication is generally sufficient to ensure that people get the right medication at the right time so ensuring their health needs are met. EVIDENCE: Staff were observed talking to individuals throughout the day and asking them how they were. Staff gave people an opportunity to talk about what they had been doing, how they were feeling and if they had any concerns about anything. The people living there appeared to be comfortable talking to staff and approaching them if they wanted anything. All the people who live there were well dressed and had individual styles of hair and dress. One person got changed before their evening meal and staff said that he gets dressed up for dinner every evening, as he feels this is important. Staff were observed helping him to do his tie up and put his belt on. Records sampled showed that people are supported to have regular check ups with the dentist, optician and where appropriate the chiropodist. Where Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 16 appropriate individuals were referred to health professionals who are involved in their care. Since the last inspection one person had been referred to the community nurse. They had visited and provided support and advice to staff to help meet the person’s health need. Each person had a health action plan that was produced using pictures making it easier to understand. This is a personal plan about what support the person needs to stay healthy and what health services they need to access. This included how the person communicates when they are in pain, happy or unhappy, the people who help the individual to keep healthy and the person’s health needs. Individuals had signed their health action plan where they are able to showing that they had been involved and agreed to it. One person’s plan stated that they should be weighed weekly. This had been recorded weekly until 24th August but not since and showed that the person had lost 2kg in a month. Another person had been weighed monthly until July but not since. The deputy manager said they had purchased new scales so would make sure that individuals are weighed when they need to be. This will ensure that staff can monitor if people are losing or gaining weight so to ensure their health needs are met. Records showed that each person had an annual health check at the GP surgery. Medication is stored in a locked cabinet. One member of staff takes responsibility for the medication management systems to ensure it is organised so that people get their medication as prescribed. Currently a pharmacist in Lye supplies the medication to the home but the Deputy Manager said they are soon going to change to a local Boots who will provide the monitored dosage system to make it easier. Staff who have received training in administering medication give it to the people living there. Two staff sign the Medication Administration Records (MARS) to say that it has been given. The MARS sampled were all signed appropriately indicating that medication had been given as prescribed. At the front of each person’s MARS there was a photo of them so that unfamiliar staff would know what medication to give to whom. One medication for one person was in a bottle and the label on it had been coloured over with a highlighter pen. Staff said this had been done so that the person’s bottle could be distinguished from another person’s who takes the same medication. However, this made it difficult to see the label and what was in the bottle. Staff were advised to get another label from the pharmacist to ensure that the label is not covered. An alternative way should be found to distinguish the bottles without obscuring the label. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the views of the people living there are listened to and acted on. Arrangements are not sufficient to ensure that the people living there are always protected from abuse. EVIDENCE: The AQAA stated that the home had not received any complaints in the last twelve months. There had been no complaints made to the Commission since the last inspection. Some compliments had been received and these were displayed in the notice board in the hall. The people living there said they knew who to speak to if they were unhappy and how to make a complaint. Staff had not received training in the Mental Capacity Act but the Deputy Manager said they had been looking for training providers and the seniors and managers would go on training first. This legislation came into force in April this year and requires an assessment to be completed of the person’s capacity before they make a decision. If people are assessed as not having the capacity then this decision must be made by others and documented or support given to the person to make the decision. Training records showed that all staff had received training in adult protection and the prevention of abuse. All staff had received training in CPI (an accredited form of intervention that uses physical intervention only as a last resort). Behaviour management strategies sampled showed how staff are to respond to individual’s behaviours using CPI techniques. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 18 Each person has an inventory of their belongings that is updated when they buy new things and signed by the individual and a member of staff. This helps if things should go missing to track what possessions the person has and when they last had it. One member of staff takes responsibility for the management of individual’s finances to ensure they are organised and people are protected from financial abuse. Two people’s finance records were sampled. On one of these records there were three errors noted on the calculations on the current record resulting in their money being 10p short. The Deputy Manager replaced this immediately so the person was not short of this. They said they would check their record, rectify it and talk to staff to ensure the errors are minimised. The calculations on the other person’s records were correct and their record crossreferenced with the amount in their wallet. Their money had been spent on personal items and receipts were kept of all purchases. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are not always sufficient to ensure that people live in a homely, comfortable and safe environment. EVIDENCE: In the dining room the table had been moved to the middle of room so it was not against the wall as at previous inspections. This provided more space for people to sit around together and the table does not bash against the wall, which damages it. There is a computer that the people who live there can use. New curtains had been fitted and the curtain rail had been fixed. The Deputy Manager said that the paintwork in the dining room is to be repainted. Since the last inspection new saucepans, utensils, crockery and cutlery had been bought so there were now adequate quantities of these. The cooker is a domestic size but staff said it is sufficient and is in good working order. Hand towels and wash were provided at the wash hand basin in the kitchen. Staff said that they plan to replace the flooring and blinds in the kitchen to make it clean and more comfortable. New flooring had been provided in the WC and lobby leading to the laundry. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 20 Staff said that a replacement piece is to be ordered for the broken window ledge in the lounge. New flooring had been provided. Staff said the lounge is to be redecorated and the people living there will be supported to buy some new pictures. The radiator cover that was previously broken had been replaced. A new carpet had been fitted on the stairs. This replaced the old one that was worn in places, which could have been a trip hazard. Individual’s bedrooms were personalised and decorated according to individual tastes and interests. Two bedrooms had recently been re-decorated. One of these was decorated to a good standard in the colours that the person had chosen. In the other bedroom the decorators had used two different colours over one wall and had painted over a damp patch instead of letting it dry out so the wall had damp patches on it again. The Deputy Manager said they have got a quote to have it redecorated by another company and this would be completed soon. The person said they have chosen the colours for their room to be painted in. New curtains had been provided in one person’s bedroom and a new carpet in another person’s. Each person had a lock on their bedroom door and people who could use their key had locked their bedroom when they went out to keep it private. The locks fitted were a type that needed an individual key to open it and could not be opened for staff to gain access to the room in an emergency. These must be replaced so that people are safe. Staff said that the shower room on the second floor is going to be redecorated to brighten it up. As at the last inspection the shower rail was loose and action needs to be taken to ensure it is safe. On the front door there was a bolt at the top. Staff said this is used when two people are at home as they are vulnerable if they go outside the door on their own because of the road. The door is alarmed to let staff know when it is opened but this is not always enough time for staff to get to the door to ensure that people are safe. A member of staff was observed using a chair to reach the bolt and open it. The deputy manager said that they would advise staff not to climb on chairs in case they fall. They were advised to check with the fire officer to ensure that if there was a fire all the people living there and staff would be able to get out. In the garden a new gate had been fitted providing more security but could be opened easier from the inside so that in an emergency people would be able to get out. A large trampoline had been provided that was covered around so it was safe for people to use. Staff said that the external paintwork is to be repainted. New garden furniture had been provided. The home was clean and free from offensive odours. Staff and the people living there clean the home. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements had significantly improved to ensure that the people living there are supported by competent, well supported and qualified staff. The people living there are protected by the homes recruitment practices. EVIDENCE: The AQAA stated that 41 of staff have National Vocational Qualification (NVQ) level 2 or above in Care but another five members of staff are working towards this qualification. The standard is that at least 50 of staff have achieved this qualification to ensure they have the skills and knowledge to meet the needs of the people living there. Although, they have not yet achieved this standard progress is being made and the Deputy Manager said that two of the senior staff are working towards NVQ level 4. They plan to finish this by the end of this year. Staff rotas sampled showed that the minimum staffing levels are met. There were sufficient staff on duty so that staff were able to support individuals to meet their needs and achieve their goals. The Deputy Manager said there was one full time vacancy. Some staff had been absent due to sickness and they had used some agency staff to cover but they do not usually use agency staff. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 22 Staff meeting minutes showed that at least six staff meetings had been held in the last year, which meets this standard. Staff discussed person centred planning, Protection Of Vulnerable Adults (POVA) policy, record keeping, risk assessments, staffing, individual needs of the people living there, medication, care plans, decorating and the management of the home. Three staff records were sampled. One of these was still held at the Head Office in London and the Deputy Manager said they were being brought to the home later that week. This was the member of staff’s first shift at the home. The other records included the required recruitment records including evidence that a Criminal Records Bureau (CRB) check had been undertaken. This helps to ensure that ‘suitable’ people are employed to work with the people living there. Staff said that their start date had been delayed until the required records including a CRB had been received. Staff training records sampled showed that staff had received training in fire safety, moving and handling, health and safety, POVA, first aid, CPI (an accredited form of intervention), autism awareness, medication and Makaton. The Deputy Manager said that all staff had completed a two - day CPI training. He is the instructor and in September completed a three - day update before delivering the training. A training needs analysis was completed in July this year for the staff team to identify what training was needed so that staff could meet the individual needs of the people who live there. Staff said that when they first started working at the home they completed the Skills for Care induction, which provided them with the skills and knowledge they needed to do the job they were employed for. Staff records sampled showed that staff had regular, formal, recorded supervision sessions with their manager. In these sessions they set targets as to what they were going to achieve to improve their performance so they could meet the needs of the people living there. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements had improved so that the people living there benefit from a well run home. The people living there cannot always be confident that their views underpin all self-monitoring, review and development by the home. Arrangements are not always sufficient to ensure that the health, safety and welfare of the people living there is promoted and protected. EVIDENCE: Since the last inspection the Commission refused registration to the acting manager. Another manager was recruited who started in June but had to leave for family reasons. A Deputy Manager was recruited and is the acting manager until the newly recruited manager starts at the beginning of November. A senior manager from the organisation had been overseeing the home and staff said that they are at the home three days a week. Findings of this inspection Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 24 show that despite several changes in the management over recent months there have been significant improvements made in the running of the home. Staff said that everything is better in the home and it is more settled. A representative of the organisation visits the home each month and completes an audit to assess the service provided. These include talking to the people who live there and asking for their views on the how the home is run. There is not a formal quality assurance system in place and staff said that the people living there had not completed satisfaction surveys for some time. Fire records included a risk assessment that stated what action is taken to ensure that the risks of there being a fire are minimised as much as possible. Staff had not recorded that they had tested the alarm weekly to make sure it is working since September 19th. However, the Deputy Manager knows that staff had tested it the week before as they found that an emergency light was not working. This was to be repaired the next day. Regular fire drills are held so that staff and the people who live there know what to do if there is a fire. An engineer regularly services the fire equipment to ensure it is maintained and in good working order. Staff test the water temperatures regularly to make sure they are not too hot or cold. The last record stated that the bath was 53.3 degrees centigrade. The recommended temperature so that people are not at risk of being scalded is 43 degrees centigrade. The Deputy Manager checked the bath temperature again and found it was 47 degrees centigrade. They said they would get the valve adjusted. The only person that uses the bath is always supervised by staff, which minimises the risk. An electrician had tested the portable electrical appliances the week before to make sure they are safe to use. A Corgi registered engineer completed the annual test of the gas equipment in February this year and stated that it was safe to use. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA26 Regulation 13 (4) (ac) Requirement Timescale for action 30/11/07 2. YA42 13 (4) (ac) All bedroom doors must be fitted with a lock that can be opened in the event of an emergency. This means that staff will be able to help the person to be safe. Outstanding from the last inspection. Water temperatures must be 18/11/07 maintained at 43 degrees centigrade so that people are not at risk of being scalded. Outstanding from the last inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The statement of purpose and service users guide should be updated with the relevant information. This will ensure that prospective service users and the people living there have the information they need about the home and the service provided. Staff should continue to encourage the people living there DS0000016734.V346744.R01.S.doc Version 5.2 Page 27 2. YA17 Ulysses House 3. YA19 4. YA20 5. 6. 7. YA23 YA24 YA24 8. 9. 10. YA27 YA39 YA42 to eat a healthy diet and inform them of how their diet affects their health. This will help to ensure that individual’s health needs are met. Individuals’ should be weighed when needed to ensure their health needs are met and a record of this should be made. This will help staff to monitor and ensure they are not losing or gaining too much weight, which could be an indicator of an underlying health need. Pharmacists labels should not be covered on individual’s medication as this may lead to people not getting their prescribed medication so their health needs may not be met. All staff should have an awareness of the Mental Capacity Act and how this legislation affects the people living there. The window ledge in the lounge should be replaced so that it is safe. Advice should be sought from the fire officer and followed regarding the use of the bolt on the front door. This will ensure that the people living there and staff are able to get out in an emergency. Action should be taken to ensure that the shower rail in the second floor bathroom is safe. A quality assurance system should be in place. This should consider the views of the people living there so that these underpin the review and development of the home. Records should be maintained of the testing of fire equipment to make sure it is working. This will ensure that people are alerted if there is a fire and will have more time to get out so ensuring their safety. Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ulysses House DS0000016734.V346744.R01.S.doc Version 5.2 Page 29 - 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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