Inspection on 04/05/06 for Ulysses House

This inspection was carried out on 4th May 2006.

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 19 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 15/10/07

Ulysses House 19/04/07

Ulysses House 10/10/06

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 Unannounced Inspection 4th May 2006 09:10 Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 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.V289989.R01.S.doc Version 5.1 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.V289989.R01.S.doc Version 5.1 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 Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 12th October 2005 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 resident has their own bedroom that has been tastefully decorated, 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. The home offers 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. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this inspection over one day. The information was collected in a number of ways including observation of care practices, talking with the people who live there, the staff and a tour of the premises. Health and Safety, staff records and the files about the people who live there, were sampled. This was the first inspection of 2006/07 and all the key standards were looked at. What the service does well: What has improved since the last inspection? A lot of things have improved and residents said that they were happy living there. There is a pool table and table football game in the dining room for residents to use. A new TV has been bought for the residents to use in the lounge. Several rooms have been redecorated making it a nicer place to live in. The flooring has been replaced in one resident’s bedroom. Resident’s contracts include all the information they need so that they are aware of the terms and conditions of their stay. The medication cabinet is secured to the wall and staff that give medication to residents have had ½ day training in this. Residents know how to make a complaint and have the details of the CSCI to contact if they need to. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 6 Some staff have had training in adult protection so that they know how to keep residents safe from harm. The dishwasher and tumble dryer have been repaired and were working properly. Staff were aware of what activities each individual resident was doing and made sure that they supported them to do these at the right time. What they could do better: 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. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 7 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.V289989.R01.S.doc Version 5.1 Page 8 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents do not have all the information they need to make an informed choice about living at the home. Each resident has a written individual contract stating the terms and conditions of their stay. EVIDENCE: Residents records sampled included a service users guide. This included all the relevant and required information. When a new manager is in post this will need to be updated with their details. The guide was not in an accessible format so that it is easier for the residents to understand. The statement of purpose had not been updated since July 2004 and there have been a number of changes at the home since then. It did not include the relevant and required information. The Acting Manager said that there have been no referrals for residents. At the last inspection the assessment process for a resident who had recently been admitted was looked at. This standard was not assessed at this inspection. Residents records sampled included an individual contract stating the terms and conditions of their stay at the home. The residents relative and the Registered Manager had signed one of the contracts. The other contract was Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 9 not signed. The Acting Manager said that as the resident does not have contact with their relatives an independent advocate would need to be involved to support the individual in this. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs and goals are reflected in their individual plan so that staff know how to support them. Residents make decisions about their day-to-day lives but are not adequately consulted on in all aspects of life in the home. Residents are supported to take risks within a risk assessment framework. EVIDENCE: Residents records sampled included an individual care plan. These detailed how staff are to support the individual with their personal hygiene, health needs, managing their behaviour and where appropriate their aggression, self- help skills, relationships and social and leisure activities. Each resident has a key worker and a co-worker who meet regularly to evaluate the individual’s care plan and what action they need to take to ensure that the individuals needs and goals are met. Residents spoken to knew whom their key worker and coworker was. Resident’s daily records showed that residents are able to make decisions about their day-to-day lives. Staff were observed talking to residents and Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 11 encouraging them to make choices about what they want to do and where they want to go. Regular formal residents meetings do not take place. The last meeting was in March 2006. Staff said that they hope to arrange these monthly. One resident said at the last meeting that they would like to go ice skating, but they have not yet been. The Acting Manager talked to the resident about arranging this. One resident said that they would like to have swimming lessons and they have started these. All residents talked about getting some garden furniture and some games and activities that they could do outside. No action has yet been taken but the Acting Manager said that now the weather is better these would be looked at. Resident’s records sampled included individual risk assessments that detailed how staff are to support the individual. Some risk assessments stated dates on which they should be evaluated but there was no evidence that this had been done. There were several risk assessments relating to the same risk and it was not always clear which was the most recent. It would be useful for risk assessments no longer relevant to be archived so that it is clear what the current assessment is. Staff had signed to say that they had read and understood risk assessments. An incident had occurred the previous day where one resident had behaved in a way that they had not done previously. A neighbour raised concerns about this behaviour. An immediate requirement was left for the residents risk assessments and care plan to be reviewed and updated as necessary to ensure that risk are minimised and the individuals needs are met. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are generally adequate to ensure that people living in the home experience a meaningful lifestyle. Residents being given the opportunity to go on holiday would improve this. Adequate evidence is not available to show that residents are offered a healthy diet. EVIDENCE: Each resident has an activity plan that is displayed in the office. The Acting Manager talked to some residents about reviewing these with their key worker. Two residents went with staff to Drayton Manor Park for the day by public transport. One resident attends a work placement four days a week. It was their day off; they chose to go to local shops and also attended a health appointment. One resident went to a computer class at college. One resident went to the local shop and then went to a local shopping centre for lunch and shopping. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 13 The Acting Manager asked one resident whether they would like to go on a day trip to Drayton Manor sometime, they said ‘no’ but would like to go to Blackpool. The Acting Manager said that no holidays have yet been planned for residents this year. Residents activity plans showed that they make telephone calls to relatives. One resident went to their parents over the Easter holiday. Residents said that they are supported to visit their relatives where appropriate. Residents care plans stated how staff are to support them to develop their selfhelp skills. One resident was putting away his clean laundry. Staff supported another resident to clean his room. Residents records sampled showed that residents help to prepare meals, do household tasks and do the house food shopping with staff. Two weeks of food records for each of the two residents records sampled were looked at. The Government recommendation for a healthy diet is five portions of fruit and vegetables each day. Food records did not indicate on any day that this was provided to each resident. However, in the kitchen plenty of fresh fruit and vegetables were provided. The Acting Manager said that fresh vegetables are often provided within meals but these are not recorded adequately. For example some records stated Spaghetti Bolognese, Chicken Curry and Sausage Casserole. It is likely that vegetables were included in these dishes but these were not recorded. Some of the records were not completed. Staff were talking to residents about choosing healthier options to eat. This could be developed further in residents meetings using video and accessible material available about healthy eating. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and require. Arrangements are not adequate to ensure that all the health needs of residents are met. Staff have not received sufficient training to ensure that residents are fully protected by the homes medication procedures. EVIDENCE: Residents care plans sampled included how staff are to support individuals with their personal care and hygiene. Staff were observed supporting residents to change their shoes so that they were more appropriate to go out for the day and prompting residents to put a belt on their trousers. Staff that were supporting residents to Drayton Manor Park took sun cream to protect residents from sunburn. Residents were dressed appropriately to their age, the weather and the activities they were doing. One resident was wearing an Irish rugby shirt and this reflected part of their cultural background. Residents records sampled showed that health professionals are involved in their care. Each resident is registered with a local GP. Resident’s records did not include a Health Action Plan in line with the Government White Paper Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 15 ‘Valuing People’. This is a personal plan about what a person needs to stay healthy and what services they need to access. One resident had a folder that included health checks and assessment for a health action plan. They said they were going to work on this with their community nurse. Residents had been weighed regularly and a record of these kept. The medication was stored in a locked trolley that was secured to the wall. A pharmacist in Lye supplies the medication to the home in blister packs. Staff said that this is delivered by the pharmacy. The Acting Manager faxed the prescriptions to the pharmacist and the medication was to be delivered later in the afternoon. Staff had signed all medication administration records (MAR) appropriately. The MAR cross-referenced with the blister packs indicating that medication had been given as prescribed. Senior staff give medication to the residents. The Acting Manager said that this could be a problem if the senior staff is off sick, as this has to be covered by another Senior or the Manager. Staff have received a three-hour training session in the safe handling of medication. A requirement was made at previous inspections for staff to receive accredited training in the ‘Safe Handling of Medicines’ and this remains outstanding. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure ensures that resident’s views are listened to. Arrangements are not fully adequate to ensure that residents are protected from abuse, neglect and self-harm. EVIDENCE: Residents records sampled included a complaints procedure that had the details of the CSCI so that residents are aware that they can make a complaint to the CSCI also. There have been no complaints received by the home or the CSCI since the last inspection. One residents records sampled included a letter from their relative stating how pleased they were with the support their relative was receiving and how much the person’s behaviour had improved. Resident’s records sampled included individual risk assessments about financial abuse and what steps need to be taken to ensure these risks are minimised. Records sampled included bank statements that showed that their benefits were paid into their account regularly and they regularly withdraw their personal allowance. Residents have their own bank accounts and said that they withdraw their own money with support from staff when necessary. Resident’s personal money is kept securely in the home and records are kept. Two records were sampled and these cross-referenced with the amount in their individual wallets. Receipts are kept of all purchases. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 17 Residents records sampled included an inventory of their belongings that had been updated regularly as they had bought new things. Individual behaviour management strategies were in resident’s records. One resident’s records included advice from the Psychiatrist to try using a stress ball to relieve the person’s anxiety. The previous Manager had discussed with the individual to try using a ‘mood’ diary so that they could assess possible triggers for their behaviour and develop strategies to manage it. Neither of these suggestions had been tried. Staff use Crisis Prevention Institute (CPI) physical intervention when necessary to assist residents to calm down and to prevent them hurting themselves and others. Physical intervention had been recorded appropriately in resident’s records. When physical intervention had been used staff sat with the individual resident to talk about the incident to see if they were now in control, anything that could have been done better, negotiate a contract and give the responsibility for the behaviour back to the individual. The previous Manager had completed all these records. The acting manager said that this post- vention strategy would continue, when necessary. The previous Manager was a CPI instructor and trained staff in this. They also provided practical sessions in CPI to staff twice weekly so they could keep updated in their knowledge and practical skills. Another member of staff has offered to do the training to be a CPI instructor so that this can continue. The funding of this should be considered so that the skills gained are not lost which could ultimately put residents at risk. Most of the staff received training in adult protection in November 2005. New staff employed since then have not received this. The Acting Manager said that they would check who needs this and book the training. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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 generally adequate to ensure that residents live in a homely, comfortable, clean and safe environment. EVIDENCE: Since the last inspection several rooms have been redecorated including the office, dining room and lounge. A new TV has been provided in the lounge. The old TV was positioned on a shelf, the new one is larger and is easier for residents to see. One resident’s room has had new flooring fitted, most of which is carpet with some lino fitted around the wash hand basin to make it more practical. Two residents have had astro-ceilings fitted in their bedrooms, which light up in the dark and provide a sensory effect. The WC on the first floor was showing signs of wear and tear and will need to be redecorated and the flooring replaced. Hand wash and hand towels were provided as was a lidded bin to maintain good hygiene. All the cupboards doors were fitted in the kitchen and none of the drawers were broken. The dishwasher was working. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 19 In the dining room there was a pool table and table football game, which residents said they enjoyed using. In the garden there is a shed, picnic table and a large grassed area. There is a brick built barbecue but the grill needs replacing so that it can be used. Residents had discussed at meetings how they would like to use the garden more and would like some games and activities for the garden. There were gaps in several parts of the garden fence and some bits were broken. This must be repaired so that the garden is a private space for the residents to use. In one residents bedroom there was a portable heater. The resident said that they use it to keep them warm. There were two portable heaters in the lounge. The Acting Manager said that the night staff will sometimes use them on cold nights to supplement the heating but said that the one from the resident’s bedroom would be moved that day. The home was not cold and sufficient bedding was provided in resident’s bedrooms. The carpets and flooring were clean however several of the skirting boards were very dirty and the home would benefit from a more thorough clean. The home was free from offensive odours. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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): 32, 33, 34, 35, 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Adequate arrangements to ensure an effective staff team who are appropriately trained and supported to meet residents’ individual needs are not in place. Residents are not adequately protected by the homes recruitment practices. EVIDENCE: The Acting Manager said that he and one of the senior staff have nearly completed their NVQ level 3 and would then be doing level 4. Three members of staff are doing NVQ level 2 in Care and one member of staff has level 2. One member of staff has NVQ 3 and another is doing this at present. Therefore at least 50 of staff have NVQ level 2 or above or have nearly completed it, which meets this standard. The Acting Manager said that agency staff are rarely used now, only if there is sickness that cannot be covered by regular staff. They said that they would benefit from more male staff being available to ensure that the gender balance of staff to residents is even. Rotas showed that minimum staffing levels are being met and that agency staff are rarely used. This is an improvement from previous inspections and helps to ensure that staff are consistent in meeting the residents needs. On the office wall there is a pictorial rota that is updated Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 21 daily so that residents could see who is on duty that day, which relieved some of their anxieties. Staff meeting minutes showed that these are held monthly and are attended by the owner or the consultant employed by the owner. They suggested that in order to ensure that agreed actions are followed up the minutes should state who is responsible for the action and by when. Minutes showed that night staff did not attend meetings. Consideration should be given to changing some of the times of meetings so that night staff can attend and can receive the same information as day staff and have an opportunity to share their views and be a part of the team. Two staff recruitment records were sampled. One of the records included the required records. However, the other record only included one written reference instead of the required two and there was no evidence that a Criminal Records Bureau (CRB) check had been undertaken. The Acting Manager said that the member of staff had completed the form incorrectly and another CRB form had been sent the day before. A risk assessment must be in place for this member of staff working with residents until a satisfactory CRB check has been received. Staff training records sampled showed that staff have had training in fire safety, food hygiene, health and safety, infection control, first aid, a skills for care induction, CPI physical intervention and a ½ day ‘Safe Handling of Medicines’. All staff that give medication to residents must complete accredited training in this. Many of the staff had adult protection training in November 2005 but staff that have been recruited since then have not received this. Staff records sampled did not include evidence that staff receive regular, formal recorded supervision sessions. The Acting Manager said that seniors and Team Leaders are now responsible for this and they aim to start this month. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home but staff are not always motivated by the management of the service which could impact on the residents quality of life. Residents views do not always underpin all self-monitoring and development by the home. Adequate arrangements are not in place to ensure that the health, safety and welfare of residents is promoted and protected. EVIDENCE: The Registered Manager left the week before. Staff said that he was an excellent Manager who improved things for the people that live in the home. The owner has told the CSCI that a new Manager has been appointed who will be starting later this month. The Deputy Manager is currently the Acting Manager. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 23 A consultant employed by the owner visits the home monthly and sends a report of that visit to the CSCI as required. This includes seeking the views of residents and staff. Minutes of resident’s meetings sampled showed that resident’s wishes are not always met. Fire records showed that an engineer regularly services the fire equipment. Staff usually test the fire alarm weekly but this had not been done the previous week. Regular fire drills take place with all residents involved so that they can practice what to do if there is a fire. Staff had highlighted through testing the fire equipment on 19/4/06 that the office door was warped and not closing properly and this was reported to the owner. This had not been replaced. Staff test the water temperatures regularly to make sure they are not too hot or cold for the residents. Records of these showed that the bathroom sink was 35.7 degrees centigrade, the bath was 36.6 degrees centigrade and one resident’s bedroom sink was 30.5 degrees centigrade. The recommended temperature is 43 degrees centigrade so these temperatures are too cold and no action has been taken to rectify these. Staff generally tested the fridge and freezer temperatures daily and kept a record, which showed that these were within the limits for safe food storage. However, there was a gap of eight days up until 3/5/06. Staff said that they had not received their pay slips although they had been paid the previous week. The pay slips arrived during the day. Some staff reported that there were discrepancies in their pay and this had happened previously. They said that this affected their motivation. Staff do not receive pay if they are absent due to sickness. However, the sickness absence level is high. Appropriate systems should be in place to ensure that staff receive the money they have earned and that they are motivated to ensure the residents needs are met. A valid certificate of employers liability insurance was displayed. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 25 CHOICE OF HOME Standard No Score 1 2 2 X 3 X 4 X 5 3 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 3 27 2 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 2 Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 4(1) (a,b, c) Requirement Timescale for action 31/08/06 2. 3. YA9 YA17 13 (4) (a, b, c) 17 (2) 4 (13) The statement of purpose must contain the following information: the name and address of the provider and manager, the details regarding the admission process should be expanded to include the assessment process and if trial visits will be available, the details of how activities are planned, funded, staffed and frequency with which they are undertaken, the complaints procedure must detail that the CSCI can be contacted at any time, the measurement of room sizes and the homes locked door policy.(Previous timescales of 31/05/05 & 31/07/05 not met).) All risk assessments must 31/05/06 be regularly reviewed and updated as necessary. Records of food and drink 05/05/06 provided to individual residents must be DS0000016734.V289989.R01.S.doc Version 5.1 Page 27 Ulysses House 4. YA19 12 (1) (a, b) 5. YA20 13(2)18(1)(a) 6. YA23 13(6) 18(1)(a, c) 7. YA23YA34 19 (1), Schedule 2 8. YA34YA23 13 (4), 19 9. 10. 11. 12. YA27YA24 YA24 YA30 YA36 23 (2) (b, d) 23 (2) (b, o) 23 (2) (d) 18 (2) completed daily. They must evidence where fruit and vegetables have been provided. Each resident must have a Health Action Plan in line with the Government White Paper ‘Valuing People.’ Staff who administer medication to residents must receive accredited training. Evidence that staff have received this training must be available in the home. (Previous timescales of 30/09/05 & 31/12/05 not met). All staff must be trained in adult protection procedures and a record of the training kept including date, duration, title and organising body. Recruitment records must contain all documents as detailed in Schedule 2. These must evidence robust checks have been made. Risk assessments must be in place that detail how the risks to residents are to be minimised for any member of staff for whom a satisfactory Criminal Record Bureau (CRB) check has not been received. The first floor WC must be redecorated and the flooring replaced. The garden fence must be repaired. All areas of the home must be cleaned thoroughly. All staff must receive regular formal, recorded DS0000016734.V289989.R01.S.doc 31/07/06 31/08/06 31/07/06 30/06/06 15/05/06 31/08/06 30/06/06 30/06/06 30/06/06 Page 28 Ulysses House Version 5.1 13. 14. YA42 YA42 23 (4) c (v) 13 (4) c 15. 16. YA42 YA42 23 (4) (a, c) 12 (1) (a), 13 (4) supervision sessions with their line manager. The fire alarm must be tested weekly and a record of the testing kept. The fridge/freezer temperatures must be tested daily and a record of this testing kept. The office fire door must be replaced. Appropriate action must be taken to ensure that water temperatures are maintained at 43 degrees centigrade. 05/05/06 04/05/06 11/05/06 20/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Refer to Standard YA1 YA5 YA8 YA14 YA19YA17 YA35YA23 YA23 YA28 YA33 YA43 Good Practice Recommendations The service users guide should be produced in an accessible format for the residents. Each residents contract should be signed and dated by the resident or their representative and the registered manager. Residents meetings should be held monthly and minutes should be kept. Each resident should be given the opportunity to go on holiday each year. Residents should be offered advice and information about healthy eating. The owner should consider providing the funding for another member of staff to be trained as a CPI instructor. Staff should try using a ‘stress ball’ and a ‘mood diary’ with one resident as suggested. It is recommended that the garden be further developed to increase the use of it by residents. The time of some staff meetings should be changed so that night staff can attend. Appropriate systems should be in place to ensure that staff receive the money they have earned and that they are DS0000016734.V289989.R01.S.doc Version 5.1 Page 29 Ulysses House motivated to ensure the residents needs are met. Ulysses House DS0000016734.V289989.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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