Inspection on 11/04/07 for Wells Road Care Home

This inspection was carried out on 11th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wells Road Care Home 15/02/09

Wells Road Care Home 19/03/08

Wells Road Care Home 05/09/07

Wells Road Care Home 20/04/06

Wells Road Care Home 15/02/06

Wells Road Care Home 21/03/05

Wells Road Care Home 29/03/04

Wells Road Care Home 10/11/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Wells Road Care Home 280-282 Wells Road St Anns Nottingham NG3 3AA Lead Inspector Jayne Hilton Key Unannounced Inspection 11th April 2007 08:00 Wells Road Care Home DS0000002259.V334248.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 Wells Road Care Home DS0000002259.V334248.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. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wells Road Care Home Address 280-282 Wells Road St Anns Nottingham NG3 3AA 0115 955 5162 0115 950 2066 mvickis@ncha.org.uk 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) Nottingham Community Housing Association Carmel Hopkinson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category LD Date of last inspection 3rd October 2006 Brief Description of the Service: Wells Road Care Home is situated in the residential area of St Anns, close to shops and amenities and is registered to provide accommodation and support for up to six adults with a learning disability. The home itself is comprised of a pair of semi-detached houses joined together and the accommodation consists of communal lounge, dining room and kitchen on the ground floor and six single bedrooms with shared bathing facilities on the upper floor. There is currently one vacancy. The home has enclosed front and rear gardens accessible to residents. The registered provider is Nottingham Community Housing Association. Information on fees was not provided at the time of this inspection. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over six hours on 11th and 12th April 2006. This was the home’s key inspection for this inspection / financial year. The main method of inspection was called ‘case tracking’ which meant selecting two residents and tracking the support they receive through checking their records, observation of care practice and discussion with staff. One other service users records were also viewed. Due to the limited communication of the residents living at the home the inspector did in brief speak with both of the residents case tracked and three other residents during the inspection. Staff records were looked at and a partial tour of the premises also took place in order to assess environmental standards. Three staff members were spoken with at the home and two other staff at the Nottingham Community housing Association Office. The manager was not available due to sickness but for discussion and feedback took place with the assistant manager throughout. The pre inspection questionnaire had not been completed or returned to the Commission prior to the inspection. Comments from three service user surveys returned prior to the inspection are included within the report. A random inspection was carried out on 3rd October 2006 where two requirements were made, one in relation to medication management, for immediate action. The immediate requirement was assessed as met at this visit, leaving the other regarding decoration and maintenance work still outstanding from two previous inspections and which must be complied with by the set timescale to avoid enforcement action being taken. What the service does well: Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 6 Residents needs are assessed, which include their wishes and preferences to ensure that staff can support them, in a way, which meets their individual and specialist needs and residents are provided with a contract. There was evidence of development in meeting the communication needs of residents, with speech and language input and the subsequent production of communication tools such as pictures and symbols. Residents assessed needs are mostly reflected in their respective support plans but these require consistency in reviewing, to ensure that residents changing or increased needs are identified and met. Staff are committed to enabling residents to exercise choices and make decisions in their lives but further development of this is needed to ensure this is fully evidenced. Residents are mostly supported to take acceptable risks in order to promote their independence and quality of life. Residents’ rights are mostly respected and upheld including the right to have and maintain appropriate family and personal relationships. Complaints procedures are accessible to residents and they are protected from abuse, neglect and self- harm. The environment has a homely domestic feel and residents enjoy their food. What has improved since the last inspection? What they could do better: Where limitations and restrictions on freedom are in place these are not always fully recorded within support plans. Risk assessments were also not fully identified within support plans. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 7 There are limited opportunities for residents to participate in fulfilling, appropriate and community-based activities. Residents are not fully involved in menu planning. The system in place for the management of residents healthcare needs to be improved to ensure their needs are fully are met and improvement is required in respect of the ordering and restocking of prescriptions. Improvements are required to décor, carpets and maintenance in parts of the home are required to ensure residents live in a comfortable and safe environment. The home is not sufficiently clean and hygienic. The staffing levels may not be sufficient to meet the full needs of residents and the day-to-day running of the home. Improvements are also needed to the training provision and to ensure all staff files, contain the necessary documentation. The health, safety and welfare of residents is not fully promoted and protected. Records were not fully available for inspection. 15 requirements are made in respect of the above outcome judgements and nine good practice recommendations have been made. 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. Wells Road Care Home DS0000002259.V334248.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 Wells Road Care Home DS0000002259.V334248.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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents needs are assessed, which include their wishes and preferences to ensure that staff can support them, in a way, which meets their individual and specialist needs. Residents are provided with a contract. EVIDENCE: Through discussion with the staff it is evident that the home can meet the assessed needs of individuals admitted to the home. There is regular access and consultation with specialist professionals such as a consultant psychiatrist. There was evidence of development in meeting the communication needs of service users, with speech and language input and the subsequent production of communication tools such as pictures and symbols. The terms and conditions/contract between the home and service user were seen within the plan however, these were not signed by the resident or their representative. There was evidence of a produced service user guide located in the office, but there was no evidence that residents had been given a copy. Three residents Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 10 said, in returned questionnaires that, they were provided with information about the home before moving in and a copy of the complaints procedure was displayed in the rooms viewed. It is recommended that the registered person explores other ways to ensure service users and visitors to the home are informed how they can access a copy of the inspection report. Wells Road Care Home DS0000002259.V334248.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents assessed needs are mostly reflected in their respective support plans but these require consistency in reviewing, to ensure that residents changing or increased needs are identified and met. EVIDENCE: Five residents were present at various times of the inspection and there was evidence through documentation and observations during the inspection that staff, provide service users with the information, assistance and communication support they need to make decisions about their own lives. Residents spoken with confirmed they are consulted and informed about proposed events in the home. There are regular residents meetings where issues about the running of the home are discussed. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 12 Of the two residents case tracked there was only one person’s records that provided clear evidence on their support plans, that these are regularly reviewed to ensure that the plans are still relevant or if they need changing. The other residents support plans were overdue for review between eighteen and fourty four days. Support plans mostly cover all aspects of personal and social support healthcare and emotional / behavioural needs, however the healthcare sections need further development to ensure that residents are supported with regular health checks such as chiropody, dental checks, eye checks, hearing checks and annual well person checks. [See standard 19] The accompanying risk assessments are mostly very good, identifying when there are restrictions imposed on an individuals’ freedom. For example, due to poor road safety skills a resident may have to always be accompanied when they go out. There are risk assessments in place specific to individuals’ interests and chosen activities and for different elements of daily living. Through discussions with staff it became apparent that a sanction/limitation had been imposed on a service user, which in effect is a limitation /restrictions that had been implemented, that was not however documented in the individual support plan. There is advocacy involvement for residents that do not have family. Signs, symbols and pictures are being used to enable residents with communication needs, however further development of this is needed to help resident’s to choose meals and menus, as currently the process is only in place for weekends. Where residents are not able to agree to their support plans their representative should be asked to sign their agreement to this. A member of staff was observed to open a residents mail and stated that she had authorisation to do this, due to the residents limited understanding, however there was no written agreement to this within the residents support plan and this must be obtained. A member of staff reported that discussion had taken place in relation to potential risk of a resident using the staircase, but there was no evidence of this in the residents support plan or otherwise. It is recommended that advice be sought from the Environmental Health Officer responsible for Health and Safety to ensure that the risk is managed Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 13 appropriately for both residents and staff and that the issue is fully addressed in the residents support plan and risk assessments. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14,15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ rights are mostly respected and upheld including the right to have and maintain appropriate family and personal relationships but there are limited opportunities for residents to participate in fulfilling, appropriate and community-based activities. Residents enjoy a healthy diet but are not fully involved in menu planning. EVIDENCE: Staff spoken with recognise the importance of upholding residents’ right to privacy and dignity and were observed interacting with residents in a respectful and meaningful manner. Where relevant, support plans highlight the importance of maintaining dignity. Staff spoken with, were knowledgeable about equality and diversity and how any specific needs would be met. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 15 As the residents that live at this home are not able to use a key to their own bedrooms this should actually be recorded on relevant support plan / risk assessment in order to fully acknowledge their right to privacy and security, and how this can be best achieved. A resident has a sound monitor in his bedroom, which is used at night. A support plan must make reference to the use of this monitor and in order to fully respect his privacy it must highlight when this monitor is only to be used. These issues were highlighted at the previous inspection. Each resident has a ‘social chart’ for recording when and what activities have been participated in. These showed very little community involvement of late for the two residents case tracked. Staff spoken with stated that residents are not always motivated but activities had been limited due to staffing numbers and no drivers available for the minibus. One service user commented that weekend activities are sometimes cancelled due to low staffing levels. A resident informed the inspector that she had recently been on holiday to Spain and photographs of a trip to Blackpool were displayed in the home. There are relevant support plans indicating ways that staff, support residents to maintain contact with their family for example, with using the phone and taking residents to visit. Some residents have regular weekends away with family. A resident is currently being supported with the involvement of their social worker and advocate in a growing personal relationship. Residents spoken with said that members of staff always knock on the door and wait for an answer before entering their room. Staff were observed doing this during the inspection. From observation during the inspection it was evident that staff naturally interact with residents. Staff were observed engaging with residents who have significant communication difficulties. There are no pre - planned menus, the assistant manager reported that residents pre-plan the weekend meals and these are recorded on the communication board in the kitchen but there was no evidence to support this on the day of the inspection. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 16 Records are kept of what meals residents have taken and they appeared to be mostly varied and nutritious. There was little evidence of choice options being available, staff reported that apart from weekends staff select the meal to be prepared each day from the food stocks and that residents can have an alternative if they want. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 17 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 and 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 however the system in place for the management of residents healthcare and medication management needs to be improved to ensure their needs are fully are met. EVIDENCE: Support plans mostly cover all aspects of personal and social support healthcare and emotional / behavioural needs, however the healthcare sections need further development to ensure that residents are supported with regular health checks such as chiropody, dental checks, eye checks, hearing checks and annual well person checks. One resident’s assessment identified a concern previously about weight loss but there was no support plan in place in relation to this need. The weight record for this person had not been completed either. Another resident who requires weight monitoring did have this information within the support plan, however although the support plan details the location where the residents weight will be taken it does not state the needed Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 18 frequency of the weight monitoring and this is recommended to ensure consistent practice and well being of the resident. There was good documentation in respect of the management of catheter care and health needs of another resident case tracked. Weekly hygiene checks are also in place. The home had recently been visited/audited by the Community Pharmacist; his report shows that medication management had been greatly improved. The report did identify further training requirements for staff, which had now been facilitated. The report indicated that out of date creams had been found. The assistant manager reported that this has now been addressed and there were no identified issues in relation to out of date creams being used at the inspection. Although there was evidence that the management of medication had been improved and the outstanding requirements met, there were occasions where medication had not been ordered in sufficient time and supplies had depleted leaving the residents without their prescribed medications and this is not satisfactory and may place service users at risk if they do not receive their medication as prescribed. There was information regarding medication in the service users files, and medication profile section has been further developed to include details of adverse effects and contraindications, this should be further developed to include medication review and changes of medication. A drug error policy should be placed in an accessible position for staff in the event of an emergency and should inform staff that drug errors should be reported to CSCI under Regulation 37. Storage temperatures of medicines were now being monitored. Medication is stored securely. The medicine keys are kept securely and are handed over at each staff changeover. Staff receive appropriate training and the assistant manager confirmed competency assessments were undertaken periodically, records of these were seen. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints procedures are accessible to service users. Residents are protected from abuse, neglect and self- harm. Further training and refresher training in Safeguarding adults is needed, as is updated information on reporting protocols to ensure residents are fully protected. EVIDENCE: There is a complaints procedure and in symbol and pictorial versions also. There has been no complaint recorded since the previous inspection. A formal system has been introduced for documenting and filing complaints. The complaints procedure has appropriate time scales for response and action. A resident spoken with confirmed he would tell staff if he was not happy and two residents expressed that they knew how to make a complaint in the questionnaires returned. Relevant policies and procedures are in place for adult protection. The NCVAP [Nottinghamshire Committee For Vulnerable Adults Procedural guidance manual] is held in the home but this appeared to be the out of date version. The assistant manager confirmed she would contact the Safeguarding Adults Unit to obtain the updated protocols. Staff spoken with said they had covered Protection of Vulnerable Adults training in their induction but had not undertaken any specific training in this Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 20 since. There was some evidence that some staff have undertaken training in sexuality and abuse awareness. Staff spoken with were not fully able to explain the whistle blowing policy, but were clear they would report any concerns to their senior manager. It is recommended that all staff undertake training or refresher training in safeguarding Adults and that senior staff undertake training in referral to the Lead Agency. Staff spoken with confirmed that since the last key inspection, there had been no incidents or allegations reportable under Safeguarding Adults protocols or which should be reported under Regulation 37 of the Care Homes Regulations 2001 Policies for dealing with challenging behaviour and individual strategies are included within the support plans. Staff reported that there had been no incidence of use of restraint at the home. A sample of residents finance records were viewed and although it took some time to audit with the current system in place, these were found to be satisfactory. It is recommended that the records be streamlined. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 21 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, 25 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment has a homely domestic feel however improvements to décor, carpets and maintenance in parts of the home are required. The home is not sufficiently clean and hygienic. EVIDENCE: The lounge and dining room has recently been redecorated and with lots of pictures and photos displayed there is a personal and homely feel of the home. The carpet in these rooms however is stained and looking tired. The hallway carpet is ruffled and may present a trip hazard to residents. Where rugs are in use around the home, these should be risk assessed to ensure they do not present a trip hazard to residents or staff. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 22 The kitchen requires re-decoration, as there is evidence of a water leak on the ceiling and bare plaster sections where a boiler has been removed. Two of the kitchen drawers were broken. The staff toilet and downstairs toilet also require re-decoration to improve the environment for residents and staff. There was plaster damage in two residents’ bedrooms and all three residents bedrooms that were viewed had damaged furniture-requiring attention. The is a large garden to the front and rear of the home, which was neglected and overgrown. One resident’s room had a television cable hanging loose, which could be a hazard. The laundry facilities may not be appropriate to the needs of resident’s, as the washing machine does not have a sluicing facility. Red bags are in use to prevent cross infection. Clinical waste arrangements are in place, but not used for all residents. The assistant manager was advised to seek the opinion of the Environmental Health Officer about the washing facilities and clinical waste arrangements in relation to some identified continence issues in the home. The systems in place to prevent cross infection are not fully satisfactory. No protective gloves were viewed in the laundry and there was a lack of toilet paper supplied in the WC’s. Also one toilet and the staff toilet did not have any paper towels and towelling towels were used in the kitchen, as the paper towel dispenser was not working correctly. Although the staff member prompted a resident to wash his hands before lunch, the staff member and residents preparing food at breakfast and lunchtime did not wear protective aprons. The home was observed to smell fresh but despite there being a daily jobs and cleaning rota for staff, the home was not adequately clean in high and low places/corners. The tiles in the bathroom were dirty and one resident’s room was very dusty on the surface of shelves and the lampshade. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels may not be sufficient to meet the full needs of residents and the day-to-day running of the home. Improvements are needed to the training provision and to ensure all staff files contain the necessary documentation. EVIDENCE: The staff rota shows that two staff is on duty throughout the day with a person sleeping in and one awake at night. Management hours are in addition. Staff reported that the team has experienced some instability with the recent change of provider for the service and that at times activities and community access is limited for residents. Staff said they felt that communication between the team could be greatly improved. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 24 It is therefore recommended that a staffing review be undertaken to ensure that adequate staffing levels are provided to ensure residents needs are fully met in relation to structured activities and community access and that the garden is kept useable and tidy and that thorough cleaning of the home is maintained. Staff spoken with reported that they receive good levels of training, including Equality and Diversity issues. There was no evidence that staff have undertaken training in Infection Control or Health and safety other than those that have undertaken induction. Although there were some training records available at the inspection, the assistant manager did not have access to all of the staff files. Arrangements must be in place in the absence of the manager for all record required by regulation to be available for inspection. Also there were no staff records to show that supervision sessions are undertaken with staff, however those team members spoken with confirmed that their support is very good. The recruitment information on staff is held centrally at Nottingham Community Housing Association offices. A sample of four files were viewed there on 12th April 2007. Three of the files were found to be satisfactory and but one did not contain a photograph of the staff member as required by regulation and therefore a requirement is made in respect of this. That said through speaking with staff at the Nottingham Community Housing Association offices, recruitment practices are otherwise satisfactory and the omitted information was appears to be a genuine oversight due to the recent transfer of staff from the Health Authority. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of residents is not promoted and protected. Records were not fully available for inspection. EVIDENCE: The manager has been registered with the Commission for registration since the last inspection but was unfortunately on sick leave on the day of the inspection. Two assistant managers, on the staff team, also support the home. One of the assistant managers was present for the inspection who tried to provide the information required for the inspection, however she reported that she had only recently joined the team and unfortunately could not locate all of the information requested. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 26 Information could not be provided to evidence that monthly, unannounced visits by the registered provider are taking place. Although there are good internal policies and procedures for quality assurance, again evidence was limited that it is being put into practice. Staff reported that a recent resident survey had been carried out and that responses had been forwarded to head office for consolidation and feedback, but there was no evidence seen in the home to support this had occurred or of any previous survey feedback or action. Records could not be located at this inspection for the following: Annual Gas safety certificate, Five yearly electrical circuit safety test certificate, A fire risk assessment, System for the Prevention of legionella, Monitoring of water outlet temperatures, Up to date Portable Appliance tests, Records of visits by the Environmental Health Officer and Accident records. There was no visitor’s book available for use. There were also some food safety issues, which require addressing. Although food in the refrigerator was dated upon opening some items in the store cupboards were past their use by dates and therefore food stock rotation needs to be improved. Equipment such as the chopping boards were very worn and in need of replacement. There was no food safety management system in place apart from periodic food probing and fridge and freezer temperatures being taken. A bottle of whisky was found in a kitchen cupboard, which staff reported belonged to a resident [there was no record seen of this within the support plan or a risk assessment for its storage arrangements] One resident’s room had a television cable hanging loose, which could be a hazard. In two of the bedrooms viewed the beds were placed against radiators, which may place residents at risk of harm from high surface temperatures. Throughout the home radiators were not guarded and there was no risk assessment in place for this purpose. Action must be taken to ensure residents are not placed at risk from surface temperatures of radiators. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 27 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 2 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 1 25 2 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 1 X 1 1 X Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 28 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 YA1 Regulation 5 Requirement Timescale for action 11/07/07 2 YA6 14 3 YA7 17 All residents must be issued with a copy of the Service user Guide, to ensure they have the information they need about the home Ensure all support plans contain 11/06/07 the necessary information about the assessed needs of an individual are reviewed regularly and are up to date to ensure residents needs are fully met A record must be held of any 11/06/07 limitations imposed on a resident and full agreement sought by the individual or their representative within a support plan. Schedule 3 [q] This is in relation to the use of the monitor alarm used for one resident. And opening of resident’s mail. This will ensure the resident’s rights are promoted and upheld. Improve the risk management strategies and ensure that risks to residents are fully identified, agreed and recorded in the DS0000002259.V334248.R01.S.doc 4 YA9 13[4][c] 11/06/07 Wells Road Care Home Version 5.2 Page 29 individual plan. This is in respect of alcohol use storage of and access to. And the recently identified issue of the individual using the staircase. This will ensure that unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. Ensure proper provision and 11/06/07 record keeping in respect of resident’s healthcare needs. Improved management of healthcare within support plans will ensure residents receive appropriate healthcare checks and treatments to maintain their health and well-being. 6 YA20 13[2] Ensure residents receive their prescribed medication at all times. An improved system for reordering and auditing stocks of medication is required as the current system in use may place service users at risk if they do not receive their medication as prescribed. 7. YA24 23(2)(d) Ensure all parts of the home are kept reasonably decorated and a good state of repair internally. This is outstanding from the previous inspection, initial timescale 31/08/06 not met. Outstanding timescale 30/11/06 also NOT MET. Repair/replace the broken furniture in the identified DS0000002259.V334248.R01.S.doc 5 YA19 12 [1] 11/06/07 11/07/07 8 YA25 23[2][c] 11/07/07 Wells Road Care Home Version 5.2 Page 30 9 YA30 13[3] residents bedrooms so they are fully functional. Consult the Environmental Health Officer in respect of: Laundry facilities Clinical waste arrangements Food safety management in the home to ensure that suitable arrangements are in place to prevent infection, toxic conditions and the spread of infection at the care home. Ensure all parts of the home are kept clean. Ensure all staff files contain the necessary documentation a s required by schedule 2 Ensure all staff receives training in Infection Control and Health and Safety. As part of quality assurance, ensure monthly, unannounced visits are carried out then supply report to the Commission. Maintain system for reviewing at appropriate intervals and improving the quality of care. The system shall provide for consultation with service users and their representatives. Ensure records required to be kept by regulation are available at all times for inspection. This is a requirement by legislation to ensure the home is being conducted appropriately and which is a safe place for residents to live. The following records must be provided to The Commission for 11/06/07 10 YA30 23[2][d] 11/06/07 11 12 13 YA34 YA35 YA39 19 18 24, 26 11/07/07 11/07/07 11/06/07 14 YA41 17 11/06/07 Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 31 Social Care Inspection with the Improvement plan. Annual Gas safety certificate. Five yearly electrical circuit safety test certificate A fire risk assessment System for the Prevention of legionella Monitoring of water outlet temperatures Up to date Portable Appliance tests. Records of visits by the Environmental Health Officer. A visitors book must also be in place. In consultation with the 11/06/07 necessary authorities as appropriate, the registered person must ensure that all parts of the home to which residents have access to be so as reasonably practicable free from hazards to their safety. In respect of: Annual Gas safety certificate. Five yearly electrical circuit safety test certificate A fire risk assessment System for the Prevention of legionella Monitoring of water outlet temperatures Up to date Portable Appliance Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 32 15 YA42 13[4][a] tests. Risk assessments for surface temperatures and appropriate action taken.[Particularly in relation to the position or residents beds] Trip hazards i.e. loose cables, rugs and ruffled carpets. Personal protective clothing. Adequate Provision of paper towels, liquid soaps and toilet paper. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA5 YA16 Good Practice Recommendations Ensure signatures are obtained from residents or their representatives on their contracts. Include within the support plans, a section for mental capacity, which includes holding of keys to the front door, bedroom and lockable facilities. Improve the menu planning system and ensure residents are fully consulted about their choices and wishes. Review the current system for recording service users finances to create a more user friendly and time economic record. Use regular weight monitoring to assist with healthcare promotion and in identifying potential complications and problems at an early stage. Ensure all residents have an annual well person check Provide training in safeguarding Adults for all staff and training for senior staff and managers in reporting protocols. Replace the carpets in the lounge and dining room DS0000002259.V334248.R01.S.doc Version 5.2 Page 33 YA17 YA18 YA19 6 7 YA23 YA24 Wells Road Care Home 8 9 YA32 YA33 Ensure 50 of staff are trained in NVQ level 2 Undertake a staffing review to address the identified issues in the report. Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Wells Road Care Home DS0000002259.V334248.R01.S.doc Version 5.2 Page 35 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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