Inspection on 21/04/06 for Westgate

This inspection was carried out on 21st April 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 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westgate 02/07/07

Westgate 01/11/05

Westgate 18/05/05

Westgate 25/01/05

Westgate 23/07/04

Westgate 18/03/04

Westgate 06/01/04

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 Westgate 60 Edward Street West Bromwich West Midlands B70 8NU Lead Inspector Lesley Webb Unannounced Inspection 21 & 24th April 2006 09:00 st Westgate DS0000004827.V291643.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 Westgate DS0000004827.V291643.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. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westgate Address 60 Edward Street West Bromwich West Midlands B70 8NU 0121 580 0196 NONE 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) Swan Village Care Services Limited Mrs Paula Adkins Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2005 Brief Description of the Service: Westgate is a privately owned home which has been registered to provide personal care for a maximum of seven adults who have learning disabilities. Including Westgate, Swan Village Care Services Limited operates several other care homes in the West Midlands. Westgate is a converted Victorian house situated on Edward Street. Edward Street is currently one way and located within easy travelling distance of West Bromwich town centre. There is easy access to all local amenities such as a shopping centre, library, college, churches and leisure facilities, which provides service users with the opportunity to lead active lives within the community. Parking is restricted to permits only but Westgate has permits available for visitors to the home. The home is accessed via the main entrance at the front of the property. There is one double bedroom and five single bedrooms. There is a long garden to the rear, which contains garden furniture for the use of service users. Currently the dining room/conservatory is a designated smoking area. On the second floor, there is a self-contained flat and office for staff use. The home does not provide any lift facilities and therefore would not be suitable for a service user with mobility difficulties. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days with the home being given no prior notice of the visit. During the visit time was spent talking to service users (2 in private), interviewing staff, looking at records and observing care practices before giving feedback about the inspection to the registered manager. The people who live at this home have a variety of needs and communication barriers. This was taken into consideration by the inspector when case tracking 3 individuals care provided at the home. For example the people chosen consisted of both male and female, new and established service users, with differing communication needs and from various cultural backgrounds. Although a pre-inspection questionnaire was sent to the home in order to update information relating to service provision, information from this was not used when forming judgements due to the short period of time that the home had to complete this. This resulted in information relating to fees charged by the home not being available at the time of this report being published. Since the last unannounced inspection that took place in November 2005 two additional monitoring visits have been undertaken to check how the home is addressing requirements identified at previous inspections. Many of these have now been actioned resulting in the Commission for Social Care Inspection reassessing the service as not posing a significant risk to service users. Further work is still required to ensure the home provides an adequate service in all areas. In March of this year Swan Village Care Services Limited, the company that owns this home was purchased by Minster Pathways. An application to register a new responsible individual is yet to be received, however CSCI has met with representatives of Minster Pathways who have verbally informed CSCI of its intentions in this area. The acting manager has however recently completed her registration process with CSCI and is now the registered manager of Westgate. The inspector would like to thank service users and staff for their co-operation and assistance during the visit, where she was made to feel very welcome. What the service does well: During the visit the inspector had the opportunity to complete comment cards with 4 service users. All service users stated they like living at the home, that they feel well cared for and that staff treat them well. As one service user explained when asked, “What’s good about living here?” “I just like living here, the staff help me, the staff are very nice”. This comment was reinforced during the inspection where service users and staff were observed interacting in a positive and friendly manner. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 6 Staff also demonstrated good understanding of service users rights and responsibilities. Throughout the visit staff were seen to treat service users with respect and dignity, respecting their wishes whilst encouraging them to make choices according to their abilities. All the service users that were spoken to named various staff that they felt happy to talk to if they had a problem or wanted to complain. They also stated that they were confident that any issues they are always dealt with. Records and conversations with service users also confirm that they feel they lead full and active lives. As one service user stated, “I go to college, shopping, the pub and I went bowling last week. The staff take me out a lot here, I love it”. What has improved since the last inspection? What they could do better: The two main areas that must be given priority for improvement are medication and service users financial matters. These must include the practice of double signatures for the administration of medication ceasing immediately; all prescribed medication must be signed for, pharmacy instructions for the storage of medication being complied with and pharmacy labels being attached to all medication. Financial improvements must include the reviewing of policies relating to funding of meals taken by service users outside of the home, a new appointee being agreed with placing authorities, Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 7 clarification of the annual holiday allowance awarded to service users and making arrangements for CSCI to view any bank statements held by the home. Other areas of improvement include arranging diabetic, equal opportunities, LDAF (learning disability award framework accredited) and communication training for staff, ensuring care plans, activity planners and risk assessments are reviewed within agreed timescales, arranging for all service users to be offered keys to bedrooms, evidencing that service users are proactively supported to make choices at meal times, arranging regular chiropody for service users, ensuring health care plans are accurate and reflect needs of service users, Further improvements to the environment must also be undertaken. This includes general maintenance, decoration and the renewal of furniture. Greater care must also be taken to ensure cleanliness is maintained to infection control standards throughout the building. Finally as mentioned at the start of this summary a new provider has recently purchased the home. This has created additional requirements (see back of report) relating to changes in documentation such as policies and procedures, statement of purpose and contracts of employment. 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. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 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 Westgate DS0000004827.V291643.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 and 4. The overall outcome for this group of standards is judged to be adequate. Generally service users have adequate information on which to make decisions about suitability of the home. EVIDENCE: A previous requirement to produce the service user guide in an alternative format is now part met. During one of the monitoring visits the inspector was shown a video that the manager, staff and service users have compiled to address this requirement. Further work is required as presently all of the video is filmed within the home and does not demonstrate the full range of services offered at the home. It was also noted that the statement of purpose requires amending to reflect the change of ownership of the home. There have been no new admissions to the home since the last inspection. When assessing the homes admissions and assessment procedures the inspector sampled 3 service user files and found that 2 did not contain either a care management assessment completed by the placing authority or a copy of the homes own pre admission assessment. These were later found to have been archived. The storage of documentation was discussed with the manager (see standard 41). The service user group living at the home have a variety of differing needs. When looking at care plans and other records the inspector found that in the main the home is meeting these needs. Since the last inspection the majority Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 10 of staff working at the home have undertake epilepsy training. Diabetes training is yet to be arranged. Several service users living at the home have specific communication needs, however no evidence was found on the day of inspection to demonstrate staff have received training for one of the service users and information contained with this persons care plan did not correspond with practices observed (see standard 6). The inspector was however pleased to find that the home uses a local advocacy service to support people with decision-making. There is a comprehensive policy and procedure regarding introductory visits to the home that covers all of standard 4 of the national minimum standards. When interviewing staff some were still not able to give any details of the contents of this policy despite signing to say they have read and understood it. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, and 9. The overall outcome for this group of standards is judged to be adequate. Generally care planning and risk assessment processes are adequate and provide staff with enough information to care for people living at the home. EVIDENCE: Previous requirements to expand care plans so that they cover all aspects of personal, healthcare and social support have now been met. Since the last inspection monthly key worker meetings take place with the involvement of service users where the previous months care is discussed and monitored. Also the care planning format has been altered, ensuring daily records are correlated to evidence progress towards meeting goals set out in plans. Minutes from service user meetings indicate that policies and procedures are discussed with service users allowing them to be involved in their review. Also since the last inspection the manager has reviewed the risk assessment systems in place ensuring one format is used (previously there had been 3 resulting in confusion for staff) and assessments are now based on each person’s individual needs and capabilities. When case tracking 3 service users plans of care and risk assessments the inspector found that although improvements have been made further work is still required to ensure these are reviewed within agreed timescales. For example many care plans state Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 12 they should be reviewed monthly but records indicate this is actually occurring every 3 to 4 months. The contents of some care plans must also be reviewed to ensure their accuracy and/or staff practices amended to reflect these. For example one service users communication care plan states that the use of pictures and signs including Makaton should be used as aids to communication but neither of these were observed in use during the two-day visit by the inspector. Also when interviewing staff the inspector asked if one service user with communication difficulties uses a communication dictionary and was informed that they did not. This information does not correspond with the service users care plan that states this communication tool is in place. Evidence was found that one service user who is placed at the home is spending very little time there. Staff confirmed that the social work team are involved in this situation, with an alternative placement being sought. The inspector instructed that a detailed risk assessment be completed relating to this situation as presently the home is still responsible for this persons care and wellbeing despite them very rarely staying overnight at the home. Regular service user meetings occur in order that choices can be sought and acted upon. Records of these evidence service users involvement in planning activities, meals, decoration of the home and staff issues. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. The overall outcome for this group of standards is judged to be adequate. In the main service users are offered some choices in relation to activities and meals on a regular basis. EVIDENCE: Since the last inspection care plans have been implemented for emotional, communication and independent living skills in order that personal development needs can be addressed and monitored. All but one service user attends day placements including college, daycentres and work placements in order to take part in valued and fulfilling activities. Practices observed throughout the inspection demonstrated that the daily routines and house rules generally promote independence and freedom of movement. Where restrictions do apply such as a kitchen cupboard being locked for health and safety reasons, a risk assessment is in place and alternative choices for service users have been put into place. There is a gate located at the bottom of the stairs in the building that has been put in place to safeguard a particular service user. Risk assessments were found to be in place for all other service users regarding this restriction based on the individual’s needs and capabilities. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 14 Service users that the inspector spoke to all stated that they open their own mail and can choose what time they get up or go to bed. One service user was particularly proud to show the inspector that they had a key to their bedroom but another stated that they had not got this facility, informing the inspector, “I cannot be trusted”. When investigating this comment no evidence could be found to support it. The manager informed the inspector that the service user had previously been given a key but that it had been lost, but that staff should have replaced it. Previous requirements relating to the review and monitoring of smoking policies and practices are now met in full. Each service user has an activity timetable and activity sheets are completed to evaluate the activities undertaken. Generally service users are offered a variety of activities, including bowling, shopping, public houses, discos and occasional daytrips. The home has recently obtained the use of a mini bus on some weekends that is owned by the organisation, however the inspector still recommends that its own transport be purchased (as recommended in previous inspections) in order that further access to the community can be obtained and greater choices given to service users. It was also noted by the inspector that service users activity timetables state they should be reviewed monthly but no evidence of this could be found. Staff that the inspector spoke to demonstrated knowledge and understanding of supporting service users in relationships, explaining how this may include advising about contraception and sexually transmitted diseases. In addition to this files sampled detailed how support with relationships may include assisting with phone calls and visits. The home has a four-week rotating menu that offers two choices at meal times. In addition to this individual records are maintained detailing choices made by each service user. When looking at these records the inspector found that on nearly every occasion service users have chosen the same meal as one another and questions if they are being supported appropriately by staff to not only make choices but to understand this process. During the two day inspection the inspector did not observe any service user being given a choice at mealtimes. It was pleasing however to find that all service users have had a nutritional assessment completed and are weighed monthly in order that their dietary needs can be monitored. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. The overall outcome for this group of standards is judged to be poor. Medication practices do not promote good health and have the potential to place service users at risk. EVIDENCE: Practices observed throughout the visit confirmed that service users are given personal support in a sensitive and respectful manner. Since the last inspection all staff that administer medication have completed or are in the process of completing accredited medication training. Also the manager has been attempting to obtain service users views about funeral arrangements and effects after death. For those with communication barriers an external advocate is involved in this process. There has also been some improvement in the recording and monitoring of service users health care needs. For example records indicate that the majority of service users receive treatment from opticians, dentists, general practitioners and other healthcare professionals. Work must now be undertaken to ensure service users receive regular chiropody appointments (as one service users feet appeared to be sore with extremely long nails and when asked about treatment neither the service user or member of staff on duty could say when this had last taken place), that health action plans are completed in full and that care plans relating to health are accurate (as one service users health action plan makes no reference to Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 16 their diabetes and another service users health care plan stated that they attend speech therapy when they do not). Medication practices were scrutinised. All service users files contained consent to medication being administered and self-medication assessments were in place that have been reviewed within the agreed timescales. Records for the receipt and disposal of medication were in order. Improvements to the administration of medication must be made. These include ceasing the practice of double signatures on medication administration sheets, ensuring all medication is signed for (including prescribed creams and lotions stored in service users bedrooms), clarifying ‘as directed’ instructions with the G. P, recording when prescribed creams and lotions are opened, when they must be discarded and when they must be applied, ensuring pharmacy labels are on all prescribed medication and obtaining sample signatures of all staff who administer medication. In addition to this it was noted that the temperature in the conservatory was in excess of 28 degrees Celsius and that this could affect medication stored there (for the majority of medication temperatures should not exceed 25 degrees Celsius). A record of the room temperatures must be made at least twice a day and if after two months monitoring it is found that temperatures regularly exceed 25 degrees Celsius the medication cabinet must be moved to a different location. The inspector also recommends that a stock take of all PRN and homely remedy medication such as pain relievers be undertaken with a running total maintained for monitoring purposes. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The overall outcome for this group of standards is judged to be poor. Some practices within the home have the potential to place service users at risk, however staff have a good understanding of service users rights to complain. EVIDENCE: After checking the complaints record the inspector found that no complaints have been made since 2004 however the acting manager has introduced a 3 monthly monitoring system for complaints records which meets the national minimum standards. All service users files sampled contained the complaints procedure in picture format and evidence that this has recently been reissued to reinforce service users rights. The inspector asked service users “if you were unhappy or wanted to complain what would you do?” All service users named people working at the home, including the manager as individuals they would talk to. All stated that they were happy that these people would “sort things out”. The home has comprehensive policies and procedures for adult protection including physical aggression (many of which have been amended since the last inspection). Records also confirmed that the majority of staff working at the home have undertaken both adult protection and physical intervention training. Incident records were examined, with evidence that staff have acted appropriately when dealing with potentially aggressive situations. The inspector explained to the manager that CSCI must be notified via Regulation 37 whenever aggression is displayed against another service user (see standard 41). Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 18 Records and practices relating to service users finances were scrutinised. Personal allowance sheets are maintained for each service user and individual receipts maintained. When looking at these records the inspector instructed that the home review its policy relating to funding of meals taken by service users outside of the home. The policy currently states that the home will contribute a maximum of three pound per week per service user for them and the service user must meet any cost above this. As the inspector explained some service users do not use this money every week but are still being made to pay if a meal cost above three pound. To ensure no one is discriminated against this money should be allowed to accumulate if not used in a particular week and used as and when each person chooses. As mentioned in the summary of this report new providers have recently purchased the company that owns this home. CSCI must be sent written evidence that the previous owner has been removed as a named appointee authorised to withdraw finances from bank accounts on service users behalf and that all placing authorities have been notified of the takeover of the company and that they agree with the new nominee who will act on service users behalf. The inspector also instructed that clarification be sought and forwarded to CSCI regarding service users annual holiday allowance. One service users records stated that none was used last year and another that £188.65 was used from a total of £300. The homes policy regarding this allowance does not explain if money is not used whether this will be carried forward for the next year. Finally the inspector instructed that arrangements be made for CSCI to view bank statements of all service users and that a breakdown of each persons benefit entitlements be forwarded to CSCI as this information was not available to view during the inspection and therefore the inspector could not assess in full if the home is managing finances appropriately. Two requirements identified in previous inspections have now been met. The complaints procedure is discussed in service user and staff meetings to ensure everyone is aware of its contents and staff have been issued with a copy of the homes whistle blowing policy. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The overall outcome for this group of standards is judged to be adequate. Limited improvements to the environment have been made. The outstanding matters do not provide the people living in the home with safe, comfortable surroundings. EVIDENCE: Since the last inspection a previous requirement to measure the lighting output throughout the building has been actioned. A format has been devised for implementing a programme of renewal or repair for washbasins and vanity units however this is still to be fully instigated. A tour of the premises was undertaken with the following areas requiring attention: * The fire extinguisher in the cellar must be mounted to the wall and serviced or replaced. * The excessive temperatures in the dining room must be investigated and resolved resulting in temperatures being maintained at approximately 16 degrees Celsius. * The kitchen cupboards and surrounding areas must be cleaned and any soiled/damaged utensils cleaned and/or replaced. * The uneven flooring under the fridge/freezer must be repaired. * All food products must be dated when opened. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 20 * All food products must be appropriately stored. * All stained carpets must be cleaned or replaced. * The bathroom/shower room must be thoroughly cleaned (including removing the build up of dust) * ‘C’ bedroom requires shelves, a headboard and the wardrobe door repairing. * The toilet by room 5 requires thoroughly cleaning (including removing the build up of dust). * ‘K’ bedroom requires the torn wallpaper replacing. * The double bedroom requires painting and new curtains that fit correctly. * Any worn carpets must be replaced. * The sluice sink must be re-enamelled or replaced. * Hot and cold water outlets must be identifiable on the sluice sink. * Any mops must not be left standing in stagnant water. * All bins must have lids. 3 service users invited the inspector to view their bedrooms. All were individually decorated with personal belongings. The inspector recommends that consideration be given to implementing a refurbishment programme for bedrooms, as some items appear worn and dated. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. The overall outcome for this group of standards is judged to be adequate. Recent improvements in staff training have resulted in staff gaining further knowledge to care for the people living at the home. Generally staffing levels are maintained to a satisfactory level, however further improvements would provide further consistency of care to service users. Since the last inspection recruitment practices have improved, offering further protection to those living there, with only minor amendments outstanding. EVIDENCE: Comments made by staff and records seen by the inspector confirm that an abundance of training has been undertaken since the last inspection. Staff that the inspector interviewed demonstrated various levels of knowledge relating to the needs of service users and confirmed they had undertaken courses including adult protection, epilepsy and management of behaviours. All staff files contained profiles and individual training plans but some still require completing in full resulting (as in previous inspections). In addition to this a training and development plan and matrix viewed by the inspector indicate that 4 staff are in the process of completing equal opportunities training and 3 staff are enrolled on Learning Disability Award Framework (LDAF) Of the twelve staff working at the home 3 hold an NVQ level 2, 2 hold a NVQ level 3 and 5 are in the process of obtaining an NVQ. The staff group’s Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 22 eagerness to learn new things was reinforced by a college assessor that the inspector spoke to who stated, “They are very eager and receptive to what they are learning”. Since the last inspection staffing rotas have been expanded to include evaluation of service users present in the home, staff on shift and time spent completing domestic duties. Upon inspection of the rotas the inspector found that on some occasions staffing levels have not been maintained to acceptable levels (2 staff on duty for up to 5 service users). The manager stated this had only occurred if staff have been unable to complete their shift due to sickness. As the inspector explained systems should be in place that allow for management of staff absences and that ensure the safety of service users is not compromised. On the first day of the visit the inspector was unable to access staff files due to the manager being on leave (see standard 41). The service co-ordinator stated that no one else has a key to access these records. However on the second day of the visit the manager was present and disputed this information stating that a key had previously been given to the service co-ordinator in order that records are always accessible. Some progress has been made to ensure all staff files contain the required documentation as listed in Schedules 4 and 6 of the Care Homes Regulations 2001. However the inspector raised concerns that one member of staff did not have a Criminal Record Bureau (CRB) disclosure on file despite this being raised in the previous inspection. A previous requirement to ensure staff receive regular supervision and an annual appraisal is now partly met. Records sampled indicate that the majority of staff have received an appraisal and that all staff now receive supervision (although the amount of sessions was found to vary e.g. between 1 to 5). Westgate DS0000004827.V291643.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 and 43. The overall outcome for this group of standards is judged to be adequate. The manager has a good understanding of the areas in which the home needs to improve and how improvements will enhance the quality of service provided to those living there. Improvements must be made to the accuracy and storing of some records to ensure service users are fully protected. Further work is still required to ensure that all practices within the home promote and safeguard the health, safety and welfare of those living there. EVIDENCE: Since the last inspection Ms Paula Adkins has completed the registration process and is now the registered manager at Westgate. She holds the registered managers award, NVQ level 4 in care and numerous other qualifications. Recently she has undertaken the intermediate food hygiene award and is awaiting the results of the final exam for this qualification. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 24 Also since the last inspection the home has devised and started to implement a quality assurance system. Although basic in terms of content and context the new system gives the home a basis on which it can establish and monitor quality. The inspector looks forward to viewing its implementation and progress in the future. A development plan has also been introduced, however this needs further development to evidence that it is based on a systematic cycle of planning, action and review. It was however pleasing to note that a survey of service users views has been undertaken with the results analysed (a copy of which was sent to CSCI). A survey of families, friends and other stakeholders in the community still requires to be undertaken. Further work must be undertaken in relation to the recording and storage of information. Documentation must be open for inspection and easily retrievable e.g. care management assessments had been archived and would not have been seen if the manager had not been aware of their location and on the first day of the visit recruitment records were not accessible due to the manager being on leave and no-one else having access to these records. In addition to this further care must be taken to notify CSCI in line with Regulation 37 of the Care Home Regulations 2001. For example records were seen during the inspector that evidence potential aggression from one service user towards another and that for some periods of time the home has been without heating or hot water; both of these would be incidents that CSCI should have been notified of. Also as mentioned in the summary of this report the home has recently been purchased by Minster Pathways. Arrangements must now be made to change all documentation within the home to reflect this, including policies and procedures where the previous owners are named as points of contact, the statement of purpose and service user contracts etc and an application to register a new responsible individual must be made. A sample of records were viewed when assessing the homes health and safety working practices. Small electrical items were tested December 2005, water temperatures checked weekly, the fire alarm serviced August 2005 and the last fire drill completed March 2006. The home uses a consultancy service to complete health and safety risk assessments, however records indicate these have not been reviewed since June 2004. Records also confirm that 2 accidents have occurred since the last inspection, both of which were minor and acted upon appropriately. Improvements have also been made in relation to health and safety training that staff have undertaken. Ten of the twelve staff working at the home have undertaken first aid, eleven fire safety, nine food hygiene, ten moving and handling, six health and safety and two infection control. As in previous inspections a copy of the homes business plan is still required to be forwarded to CSCI. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 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 2 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 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 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 2 3 X 2 X 2 2 2 Westgate DS0000004827.V291643.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 5,6 Requirement The home must produce a Service User Guide in a suitable format – Part met. Requirement originally made May 2002. All staff must undertake diabetic and epilepsy training – Part met. Requirement originally made November 2005. All staff must undertake communication training specific to the needs of people living at the home. Staff must be able to demonstrate knowledge of the introductory visits policy – Part met. Requirement originally made November 2005. Information contained within service users plans of care must be up to date; relevant to the care they require and reflect practices within the home. Care plans must be reviewed within the agreed timescales. Timescale for action 01/07/06 2 YA3 18(1)c 01/07/06 3 YA4 18(a) 01/07/06 4 YA6 15 01/06/06 Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 27 5 YA9 13(4) Risk assessments must be reviewed within the agreed timescales. A detailed risk assessment must be completed for the service user who is spending very little time at the home. Service users activity planners must be reviewed within agreed timescales. ‘K’ must be offered a key to their bedroom. The home must be able to evidence that service users are proactively supported to make choices at mealtimes. All service users must be given the opportunity to receive regular chiropody treatment. Health action plans must be completed in full. Health care plans must be accurate and reflect the needs of service users. The practice of double signatures on medication administration recording sheets must cease immediately. All prescribed medication (including creams and lotions) must be signed for on medication administration recording sheets. The home must clarify ‘as directed’ instructions with the G.P. All prescribed creams, lotions and eye drops must be dated when opened, include written instructions when they must be discarded and where they must be applied. 01/06/06 6 7 8 YA14 YA16 YA17 16(2)(n) 12(4)(a) 16(2) 01/07/06 01/05/06 01/07/06 9 YA19 12(1-3) 01/06/06 10 YA20 13(2) 24/04/06 Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 28 All prescribed medication must have a pharmacy instruction label. The home must obtain a sample signature of all staff that administer and sign for medication. A record of the room temperature where medication is stored must be made at least twice a day and if this regularly exceeds 25 degrees Celsius the medication cabinet must be moved to a different location. Service users and/or their 01/07/06 representative’s views and wishes must be sought about funeral arrangements and effects after death – Part met. Requirement originally made May 2005. The home must review its policies and procedures relating to funding of meals taken by service users outside of the home to ensure everyone is treated equally. Written evidence must be forwarded to CSCI that demonstrates that the previous owner has been removed as a named appointee authorised to withdraw finances from service users bank accounts. Written evidence must be forwarded to CSCI that demonstrates that all placing authorities have been notified of the takeover of the company and that they agree with the new nominee who will act on service users behalf. The homes policy and procedure Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 29 11 YA21 12(1) 12 YA23 10(1) 12 13(6) 01/05/06 relating to service users annual holiday allowance must be reviewed and clarification sought in relation to unspent monies. Arrangements must be made for CSCI to view any bank statements of bank accounts held by the home on behalf of service users. A written breakdown of each service users benefit entitlements must be forwarded to CSCI and also retained on each persons file. The home must devise and implement a written programme of renewal or repair for basins and vanity units with target dates according to identified priority – Part met. Requirement originally made July 2004. The fire extinguisher in the cellar must be wall mounted and serviced. The excessive temperatures in the dining room must be investigated and resolved. The kitchen cupboards and surrounding areas must be cleaned and any soiled/damaged utensils cleaned and/or replaced. The uneven flooring under the fridge/freezer must be repaired. All food products must be dated when opened. All food products must be appropriately stored. All stained carpets must be cleaned or replaced. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 30 13 YA24 16(1) 01/07/06 The bathroom/shower room must be thoroughly cleaned. ‘C’ bedroom requires shelves, a headboard and the wardrobe door repairing. The toilet by room 5 requires thoroughly cleaning. ‘K’ bedroom requires the torn wallpaper replacing. The double bedroom requires painting and new curtains. Any worn carpets must be replaced. The sluice sink must be reenamelled or replaced. Hot and cold water outlets must be identifiable on the sluice sink. Any mops must not be left standing in stagnant water. All bins must have lids. 14 15 YA32 YA33 18(1)(a) (c) 18(1)(a) All care staff must hold a care NVQ 2 0r 3 or be working to obtain one Staffing levels must be maintained to the agreed levels and assessed needs of service users at all times. All documentation relating to the identification of applicants for employment must be obtained and be on file prior to the commencement of employment Part met. Requirement originally made July 2004. All recruitment documentation as detailed in the Care Homes Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 31 01/07/06 24/04/06 16 YA34 Schedule4, 6 01/05/06 Regulations must be in place at the home prior to the commencement of all staff in employment - Part met. Requirement originally made July 2004 17 YA35 18(1) All staff must be provided with equal opportunities training Part met. Requirement originally made May 2002. The home must be able to demonstrate that staff use Learning Disability Award Framework accredited training Part met. Requirement originally made May 2005. Staff training and development assessments/profiles must be completed in full. All staff must receive a minimum 01/07/06 of six supervision sessions a year. The manager must also receive regular supervision – Part met. Requirement originally made May 2002. The home must implement a quality assurance tool and ensure that it incorporates the views of service users – Part met. Requirement originally made May 2002. The home must implement an annual development plan, based on a systematic cycle of planning, action and review – Part met. Requirement originally made May 2005. 01/07/06 01/07/06 18 YA36 18(2) 19 YA39 24 Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 32 20 YA41 17, 37 schedules 1,3,4 The views of families, friends, advocates and stakeholders in the community must be sought on how the home is achieving goals – Requirement originally made May 2005. All documentation as listed in the Care Homes Regulations 2001 must be open to inspection at all times. The previous proprietors details must be removed from all documentation including policies, procedures, statement of purpose, contracts, terms and conditions of employment. CSCI must be notified in writing in line with Regulation 37 of the Care Homes Regulations 2001. An application to register a new responsible individual must be made. Ensure all staff receive training in infection control, food hygiene, first aid, moving and handling and fire safety, with certificates maintained - Part met. Requirement originally made May 2002. All safe working risk assessments must be reviewed. Risk assessments must be completed for all COSHH products. Data sheets must be obtained for all COSHH products. 01/06/06 21. YA42 13(3-6) 01/07/06 22. YA43 25 A copy of the homes business plan must be forwarded to the Commission for Social Care Inspection - Requirement DS0000004827.V291643.R01.S.doc 01/06/06 Westgate Version 5.1 Page 33 originally made March 2004. 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 Refer to Standard YA13 YA20 YA24 Good Practice Recommendations It is recommended that the home purchases its own transport A stock take of all PRN and homely remedy medication should be undertaken with a running total maintained for monitoring purposes. Consideration should be given to implementing a refurbishment programme for bedrooms. Westgate DS0000004827.V291643.R01.S.doc Version 5.1 Page 34 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westgate DS0000004827.V291643.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!