Inspection on 06/12/06 for Westley Brook Close

This inspection was carried out on 6th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 30 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westley Brook Close 23/06/08

Westley Brook Close 26/06/07

Westley Brook Close 22/02/06

Westley Brook Close 23/08/05

Westley Brook Close 22/03/05

Westley Brook Close 17/08/04

Westley Brook Close 04/03/04

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 Westley Brook Close 5,12,14 Westley Brook Close Sheldon Birmingham West Midlands B26 3TW Lead Inspector Donna Ahern Unannounced Inspection 6th December 2006 10:45 Westley Brook Close DS0000016977.V307330.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 Westley Brook Close DS0000016977.V307330.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. Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westley Brook Close Address 5,12,14 Westley Brook Close Sheldon Birmingham West Midlands B26 3TW 0121 743 2436 F/P 0121 743 2436 h6021@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Mrs Maxine Davies Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 12 residents with a learning disability under the age of 65 years. One named service user over 65 years can be accommodated. One named service user with a physical disability and a learning disability may be accommodated at the home. Details regarding how the specific care and social needs of people over the age of 65 years and those with a physical disability, Must be included in the service users plan, and be subject to periodic review. 22nd February 2006 Date of last inspection Brief Description of the Service: Westley Brook Close comprises of three individually designed modern houses situated in a quiet cul-de-sac within the residential area of Sheldon. The organisation provides 12 placements for people with learning and physical disabilities, some of whom have challenging behaviour. The premises are situated close to a wide range of amenities, including local shops, library, health centre, Sheldon Country Park and churches of various denominations. There is limited parking available in the cul-de-sac. House number 5 comprises of three single bedrooms. There is a lounge, dining area and kitchen, which include a front garden and rear garden with patio area. House number 12 has four single bedrooms, two of which are situated on the ground floor with bathrooms on the ground and first floor. The ground floor bathroom has been adapted to accommodate the needs of a service user with physical disabilities and the ground floor doorways and corridors are wide enough to permit wheelchair access. There is a large rear garden. House number 14 is adjacent to number 12 and has an interconnecting door on the first floor. The home has four single bedrooms and a spacious lounge and dining room. Three people where being accommodated in house 14 at the time of the fieldwork visit. There is a landscaped rear garden with patio area. Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit was unannounced involved one inspector and took place over one long day lasting nine hours. This was the homes first key inspection for the inspection year 2006-2007. During the fieldwork the inspector met all residents, observed the opportunities and support provided to people, looked at the premises, and read records about care, staffing, and health and safety. Time was spent with the temporary manager, and discussions took place with four care staff. The home is required to report incidents, accidents and other events that occur in the home to CSCI. These are called regulation 37 notifications. All information reported via a regulation 37 notifications since the last inspection was analysed prior to the fieldwork visit. What the service does well: What has improved since the last inspection? The temporary manager had actioned a reassessment of a resident who needs had deteriorated. Some of the risk assessments had been reviewed. A new complaints file had been set up. The temporary manager had started to look at how residents could be supported to be more independent within their own home (house 12 and 14). Residents were being supported by staff to do their own food shopping. Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 6 Staff training needs had been audited and training updates scheduled so that staff have received the required training to do their job. What they could do better: Care plans required further development so that detail plans are in place that reflects how residents should be supported by staff. Behaviour guidelines must be in place so that staff supports residents in a consistent and appropriate way. There must be an accurate record of what people have eaten so that staff can monitor that people are receiving a healthy and balanced diet. Improvements must be made to how activities are planned and monitored so that residents are supported to enjoy activities that meet their needs. Health recording and monitoring must be improved so that residents receive the medical attention they require. Health Action Plans should be active documents where this information should be recorded so that monitoring can take place and action can be taken to meet resident’s health care needs. The support required by residents during the night must be risk assessed and any support required from staff and how this must be given must be documented. This will ensure that people receive the support they need and staff are clear how and when they check people. The manager must ensure that when letters from other professionals are received information must be passed on and acted upon so that residents receive the support that meets their assessed needs. In house 14 lighting in communal areas is poor and could hinder resident’s mobility. The sliding doors leading to the dining room can be pushed forward and has the potential for fingers or hands to be caught. There were no curtains or blinds on the dining room window, which backs on to a busy road. All these must be improved so that residents live in a safe and comfortable home. The provider is required to fully review health and safety procedures in house 14 so that residents are protected from risks such as unsecured unsafe items that residents may eat or drink. Vacant posts must be appointed to so that residents benefit from a stable staff team. Accident and incident reporting and recording requires immediate review so that the provider complies with health and safety legislation and so that there is a clear audit trail of information in the Home. Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 7 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. Westley Brook Close DS0000016977.V307330.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 Westley Brook Close DS0000016977.V307330.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide require some updating and review so that prospective residents have the information they need to make a decision about if they want to live in the Home. EVIDENCE: The Statement of Purpose and Service User Guide require some updating and review. The Statement of Purpose must be specific to the Home and the resident group they care for. The Service User Guide, which should be in an accessible format for residents, should detail what the resident can expect from the Home including facilities, services and staffing arrangements. The Organisation is in the process of reviewing the service at Wesley Brook and it is expected that the two documents will be reviewed as part of this process. This will ensure that any prospective residents have the information they need to know so they can make a decision about if they want to live there. There have been no recent admissions. Current residents have lived at the Home for many years. There is one vacant bed. The organisations admissions Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 10 procedure states that prospective residents are only admitted on the basis of a full assessment. A resident needs have deteriorated and the temporary manager has appropriately requested a reassessment of the persons needs by Social Care and Health. Westley Brook Close DS0000016977.V307330.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans required further development so that detail plans are in place that reflects how residents should be supported by staff. Risks assessments must be kept under review so that residents receive the support they require to manage identified risks. Behaviour guidelines must be implemented and kept under review so that residents are supported consistently and in a way that meets their assessed needs. EVIDENCE: The temporary manager said that the organisations working alongside residents and staff to review and care plans. Each of the three houses has developed formats. Three care plans were looked at, one from Westley Brook Close quality team would be improve peoples individual care plans in different each house. Version 5.2 Page 12 DS0000016977.V307330.R01.S.doc One care plan seen had no date on and there was no evidence that it had been reviewed. Another care plan had not been reviewed since April 2005. The care plan had been presented in a booklet format in an easy read style, which is good. However, bits of information had been added in, making the document difficult to follow. Some significant information was missing and the person’s nightime needs were incomplete. The format used in house number 5 was the most comprehensive and cross-referenced to relevant risk assessments. These were also due to be reviewed. Peoples care plans were stored within files containing a lot of information some of this information should be archived so that current information is easy to access. A behaviour management plan seen, was due for review in August 2005. This must be kept under review to ensure that guidelines are still relevant and so that staff support residents in a consistent way. Another persons care plan had general information about how to distract the person when agitated but there were no details about possible triggers and how to prevent possible incidents occurring. When looking at the record of incidents in the home there were occurrence when such guidelines may of been helpful and assisted staff with supporting the person. A number of risk assessments were in place for each resident and some of these were looked at. It was good that some had been reviewed when an incident had occurred so that the control factors in place to help manage the risk were still relevant. Many of the risk assessments seen were now due for review. Some risk assessments had so many bits of information added on to the assessments it was becoming difficult to follow and it is advised that these are rewritten so that information is clear. Some risk assessments could be combined so that information is more concise and easy for staff to follow. Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents must be consulted about the range of activities that they would like to take part in. Residents are supported to maintain links with their family and friends. Improvements must be made to menu planning so that residents are offered a healthy diet. EVIDENCE: Most of the residents attend a variety of day care including day centres, college and B.I.T.A. One of the residents does not attend formal day care, two staff who are employed as day support staff (Monday- Friday) to support him in the home and to access community facilities. They have the use of their own car, which is funded through their mobility money. Care staff support another resident who chooses not to attend formal day care. They said that they enjoy Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 14 doing their knitting, needlework and like watching videos and going out shopping. Resident involvement in day-to-day tasks varies in each house this would seem mainly to do with residents needs. Residents in house 5 had been out to do their weekly shop and said they are involved in doing household jobs and looking after their bedrooms. Residents in house number 12 were prompted and supported to do household tasks like laying the table and were supported to make decisions about what they wanted to do and how they wanted to spend their time. Two residents enjoyed spending time in their room listening to music and one was watching a film before they had their evening meal. In house 14 due to peoples needs it is more challenging to enable the residents to engage in developing their independent living skills. There are some restrictions imposed within the environment due to people’s complex needs and residents require a high level of support to engage in activities. Staff spoken with on the whole recognised the importance of developing resident’s independence skills. However there is scope for further development so that all residents are fully supported within a risk assessment framework to enhance their independent living skills. The temporary manager was exploring ways that this could be achieved and the involvement of resident from house 12 and 14 in their food shopping was in the process of being introduced. A resident talked about the shopping trip they had been on and the Christmas shopping they had done and they had really enjoyed themselves. Another resident said they like to go out for something to eat or to go to the cinema. Care plans had details of the activities that people like to do. At the previous inspection the manager had discussed a monitoring system that was to be implemented so that residents response to activities was recorded. This could then help to inform future opportunities for the person. This is particularly relevant for people with limited verbal communication where staff may be making decisions on their behalf. It was disappointing that this monitoring system had not been fully implemented. There were significant gaps in some of the recording of activities. One file seen had nothing had been recorded between April 2006 and October 2006. This must be improved so that there is evidence of what people have done and the person’s response to activities to inform future planning. Some residents said they had been on holiday to Blackpool and had a nice time and some residents had been to Brean. Another resident had enjoyed a trip to London to see a show. Due to staffing difficulties towards the end of the summer not all residents have had the opportunity to go on holiday. This will need to be dealt with so that residents either have a holiday later or the allocated money for their holiday is used in an alternative way. This will ensure that all residents have equality of opportunity. Some residents spoken with said they see their relatives and friends and also make and receive phone calls. Care plans had details of residents contact with Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 15 family and relatives and staff had recorded visits and details of contact made. Some relatives were visiting at the time of the fieldwork visit and were made to feel welcome by staff and spent time in their relative’s bedroom. They were complimentary about improvements that had been made to their relative’s bedroom. Residents in House 5 said they plan their weekly menu on a Sunday night in their weekly meeting. In House 14 staff said residents do make choices or they know what people like and dislike and plan around these. The organisations own improvement plan had already identified that much work could be done around meal planning so that residents are more involved in how meals are decided upon and so that menus are balanced and healthy. Records of meals served had several gaps so there is no record of what a person has eaten. There must be an accurate record of what people have eaten so that staff can monitor that people are receiving a healthy and balanced diet. Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to the service. Efficient systems are not in place to ensure that residents receive effective personal and healthcare support this has the potential to put residents at risk. EVIDENCE: It was difficult to track and monitor health information as outcomes of appointments were being recorded in different places. Some were on health notes in the case file and others were on the Health Action Plan file. Some files seen had two different “health notes” sheets with different appointments on each sheet. The Health Action Plans were not an accurate picture of people’s health care needs. This must be addressed so that residents health needs can be properly monitored. Health Action Plans should be active documents where this information should be recorded so that monitoring can take place and action can be taken to meet resident’s health needs. The support required by residents during the night must be risk assessed and any support required from staff and how this must be given must be documented. This will ensure that people receive the support they need and staff are clear how and when they check people. This requirement remains outstanding from the previous inspection report. Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 17 Following advice from the Occupational Therapist it was assessed that a walk in shower should be provided in House 5 for one of the residents. The temporary manager was in the process of obtaining quotes so that this work can be actioned. This remains outstanding from the previous CSCI inspection report. Guidelines must be in place regarding personal intimate care so that the practice protects both the resident and staff member. This was required following the previous inspection. The needs of one resident have deteriorated. Staff have been concerned about their well being and have pursued this with relevant professionals. The temporary manager had made a referral requesting a reassessment of the persons needs by Social Care and Health. On the day of the fieldwork visit the manager was contacted and given a date for the assessment. CSCI must be kept informed of developments. Residents have not been weighed on a regular basis. Some residents weight charts had nothing recorded on them and other people had been weighed infrequently. The monitoring of peoples weight is a good indicator for the early detection of other potential health problems. A letter from a health care professional was filed with some general information on the persons care plan. The advice within the letter was about supporting a resident with dysphasia. This most recent information had not been implemented onto the persons care plan and risk assessment. An immediate requirement was made at the time of the fieldwork inspection and the temporary manager took action within a day, to address this. A resident requires diabetic retinopathy screening. An entry on their care plan in February 2005 said an appointment should come through for two weeks time. There was no further information on file other than a letter dated 16th October 2006 which had been sent as a reminder to the resident saying they need this check up done and asking them to make an appointment. It is of concern that there was no evidence that the previous recording or the letter had been acted upon and a significant amount of time had lapsed When letters arrive for residents it is the Homes practice that staff will support the resident to open their post, which is good practice. The concern is that information is not being appropriately passed on or acted upon and this then results in residents not receiving the health monitoring they require. The medication was looked at in house 14. The quantities of all medicines received and balances carried over from previous cycles must be recorded to enable accurate audits to take place to demonstrate the medicines are Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 18 administered as prescribed. All medication prescribed must be recorded on the Medicine Administration Record (MAR) chart. Westley Brook Close DS0000016977.V307330.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 at least once during a 12 month period. 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 the service. The adult protection procedure must be further development so that residents are fully safeguarded. The organisations complaints policy indicates that people will be listened to and concerns dealt with. EVIDENCE: A complaints folder was available that contained details of the organisations complaints procedure. A summary of the procedure and a picture version was also available. However, the picture version was very unclear and it was advised that this is developed so that it is accessible to residents. The complaint log was blank. The temporary manager said that the quality team had recently revamped the complaints folder and that previously received complaints would be added to the new log. No complaints had been received since the previous inspection. CSCI have received no complaints about the home. Senior managers for the home had appropriately instigated an adult protection investigation in September 2006. The Organisation had recently undertaken its own internal audit of the home as it had some concerns. CSCI were kept fully informed and an action plan has been produced to address the concerns raised. Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 20 Previous reports have required the organisation to review its Adult Protection Policy so that it embraces current legislation and fully protects residents. The inspector was informed that the policy is to be reviewed. Staff receive training on adult protection matters so that they have an understanding of their responsibility to protect vulnerable people. Staff spoken with said they would approach their manager if they had any concerns about residents well being. Westley Brook Close DS0000016977.V307330.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements are required in house 14 so that it is safe and comfortable for residents. EVIDENCE: The previous inspection report highlighted the need for the provider to plan for resident’s future needs and ensure that the house’s where possible meet residents changing needs. As stated in standard 18 there are plans in place for a walk in shower in house 5. House 12 has a ground floor bathroom with specialist shower and bathing facilities. There are concerns about one of the people who live in house 14 regarding deterioration in their health and mobility. This person has a bedroom on the first floor and is also experiencing difficulties accessing the bath. The current arrangements are having an impact on the resident as they have only limited access to their own bedroom due to the risks accessing the stairs. As highlighted previously in this report reassessments of the person’s needs are taking place and CSCI must be informed of the outcome. Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 22 Small group living is provided across the three houses and progress has been made to improve the physical standards so that each house is comfortable and safe for residents. A number of resident’s bedrooms have been decorated and very well furnished with comfortable seating and extensive personal items. Residents said that they have helped pick the paper and items for their rooms such as bedside lights. There were a number of concerns in house 14. Lighting in communal areas is poor and could hinder resident’s mobility. The sliding doors leading to the dining room can be pushed forward and also have the potential for fingers or hands to be caught as they can be pushed away from the hinge. It was felt these pose a risk to resident’s safety and there use must be reviewed immediately. There were no curtains or blinds on the dining room window, which backs on to a busy road. Suitable curtains or blinds must be provided so that residents’ dignity and privacy is protected. The lounge felt cold, staff said they are waiting for a new fire to be fitted to improve the quality of heating in the lounge. This was due to be fitted the week after the fieldwork visit. The bathroom on the first floor is in need of painting and refurbishment. Westley Brook Close DS0000016977.V307330.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 at least once during a 12 month period. 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 the service. Staff do not receive regular supervision and support sessions to enable them to do their job well and meet residents needs. Vacant posts must be appointed to so residents benefit from a stable team who know peoples needs. EVIDENCE: Staffing levels are two staff on duty at core times in house 12 and 14 and one staff on shift at core times in house 5. The manager’s hours are in addition to these. One resident in house 14 has two staff support for their day care Monday – Friday. At night there is one staff member on a waking night shift in each house. There were 100 care hours vacant, which were in the process of being appointed to. The temporary manager stated that there is some flexibility in staffing levels, which can be increased to support activities. This is really needed, as many of the people require a high level of staff support to engage Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 24 in activities at home or in the community. Staffing levels seemed adequate but must be kept under review due to the changing needs of residents. Training records were seen and certificates were available to evidence completed training. The temporary manager had identified training needs for the staff team including older people and changing needs, fire safety, food hygiene and race equality. This should ensure that staff have the required skills and knowledge to support residents. It was advised that the staff training records were developed so that the date training was due for renewal was recorded which would assist with planning future training needs. The frequency of staff supervision sessions, which are the opportunity for staff to receive feedback on their performance and to discuss staff development matters, were looked at. Staff had received supervision on an infrequent basis one staff had not received supervision since June 2006 and another since April 2006. Staff must receive a minimum of six supervisions a year so that they receive the support and supervision they need to carry out their job. The temporary manager had identified the shortfalls in supervision, which she was trying to address. However, this was proving difficult, as there are no other senior staff who can support her in this task. Three staff files were looked at and met the required standard. The organisations own internal audit had identified some shortfalls in the recruitment process that did require addressing so that residents are protected. Staff induction was not looked at during this inspection. Observations of interactions between residents and staff were positive. Staff spoken with knew residents needs well and seemed genuinely committed to the care of residents. Staff said that staff morale has been very low in recent months due mainly to the impact of an internal investigation taking place. Westley Brook Close DS0000016977.V307330.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Health and safety must be improved so that resident’s welfare is promoted and protected. EVIDENCE: The provider had instigated its own investigation into 5, 12 and 14 Wesley Brook close so that it could identify any shortfalls and improve the service for residents. CSCI have been kept informed of developments. A temporary manager had been brought in to manage the homes. She is a registered manager for another Mencap home out of the Birmingham area and has extensive experience of managing a home. Throughout the inspection process the temporary manager presented as open, positive and inclusive. The home previously had one registered manager and two assistant managers. Currently there is just the temporary manager. This has presented some Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 26 challenges; as this is a large staff team spread over three different houses. An on call arrangement is in place for when the manager is not available. Staff spoken with made very positive comments about the temporary manager saying she is “approachable” and “professional”. The provider said that when the investigation is completed a review of the service and future management arrangements will take place so that a structure is in place that best meets residents needs and enables the development of each house. The organisations quality team will be supporting the temporary manager from mid December 2006 to address matters raised in the organisations own action plan, and to improve and develop systems so that the Home is compliant with relevant policies, procedures and the aims of the Home. The service manager does monthly monitoring visits and reports of her findings are available in the home and action points are identified. There is scope to further develop quality assurance systems so that the views of residents are sought and used to help inform the planning and review of the Home. A number of health and safety records were looked at. Weekly tests of the fire alarm and monthly checks of the emergency lights are not always been tested as required. These tests must be completed as required so that good fire prevention systems are in place to safeguard residents and staff. Decanted washing powder in a plastic bag and washing conditioner was being stored, unsecured, in the laundry in house 14. These items pose a risk to one of the resident who will drink unsecured fluids and has limited awareness of the dangers. Immediate action was taken to secure these items. Similar concerns have been raised at previous unannounced inspections. The provider is required to fully review health and safety procedures in house 14 so that residents are protected from such risks. A protruding nail from a wall mounted toilet roll holder in house 12 was dealt with immediately. Accident and incident reporting and recording requires immediate review so that the provider complies with health and safety legislation and so that there is a clear audit trail of information. There must be a system for the auditing of accidents and incidents that have occurred so that issues of concern are identified and dealt with by the manager and further occurrence minimized. Some accidents logged should have been reported to CSCI via a regulation 37 form, which is the reporting of accidents, incidents or anything untoward. There were also recordings of unexplained bruising. These must also be reported to Social Care and Health and CSCI so that they can make a decision about whether further enquires is required. Westley Brook Close DS0000016977.V307330.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 2 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 X X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 2 X 2 X 2 X X 1 X Westley Brook Close DS0000016977.V307330.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 2 3 4 5 6. 7 Standard YA1 YA1 YA6 YA6 YA7 YA9 YA12 Regulation 4 (1) 5 (1) 15 (2) b 15 (2) a, b, c 12 (1) a 13(4a, b, c) 16 (2) m, n Requirement The Statement of Purpose requires review. The Service User Guide requires review. Care plans must be kept under review. Care plans required further development so that they are comprehensive documents. Behaviour guidelines must be implemented and kept under review. Risk assessments required further development and review. Residents must be offered a choice of activities. The range and choice of activities must be kept under review. Systems must be implemented for the evaluation of activities so that there is a way of monitoring what people have enjoyed and may like to do again. Records of food must include an accurate record of what residents have eaten. Timescale for action 31/03/07 31/03/07 31/01/07 31/01/07 31/12/06 31/12/06 31/01/07 8 YA13 16 (2) (m) 31/01/07 9 YA17 16 (1) (I) 25/12/06 Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 29 10 YA18 12 (1) a 11 YA18 12 (1) a & (3) 12 13 YA19 YA19 12 1 (a, b) 12 (1) (a, b) 14 15 YA19 YA20 12 1 (a, b) 13(2) 16 YA20 13(2) 17 YA23 13(6) 18 19 20 21 YA24 YA24 YA24 YA24 23(2) b 13 (4) b 23 (2) b 23 (2) b The support residents require during the night must be risk assessed. Records of monitoring by waking night staff must reflect the risk assessment. Guidelines must be in place regarding personal intimate care so that the practice protects both the resident and staff member. This was required following the previous inspection. Monitoring of people weight must take place and a record must be kept in the home. Care plans must incorporate what advice from other professionals has been sought and how this has been implemented into the persons care plan. Health care recording must be improved. The quantities of all medicines received and balances carried over from previous cycles must be recorded to enable accurate audits to take place to demonstrate the medicines are administered as prescribed. All medication prescribed must be recorded on the Medicine Administration Record (MAR) chart. The Adult Protection Policy and Procedure required some development (Previous requirement September 2004). A review of the lights in house 14 is required. A review of the sliding doors is required as it posses a risk to residents. Suitable blinds or curtains are required for the dining room window in house 14. The bathroom requires painting in house 14. DS0000016977.V307330.R01.S.doc 31/12/06 31/12/06 31/12/06 13/12/06 31/12/06 31/12/06 31/12/06 31/01/07 31/01/07 31/12/06 31/12/06 31/01/07 Westley Brook Close Version 5.2 Page 30 22 YA29 23 (2) n 23 24 25 26 27 28 29 YA33 YA36 YA37 YA39 YA42 YA42 YA42 18 (1) a 18 (2) 4 (1) a 12 (1) a 24 23 (4) c (v) 13 (4a, b, c) 13 (4) a, b, c 30 YA42 17 (20 schedule 4 12 (a) and 16 CSCI must be kept informed of development regarding suitable adaptations to meet resident’s needs. Vacant posts must be appointed to. Staff must receive the supervision they need to do their job. A review of the management structure for the home is required. Quality assurance system must be further developed. The fire alarm system must be tested as required. COSHH items must be secured at all times. The provider is required to review health and safety procedures in house 14 so that residents are protected from risks to their health and safety. Accident and incident reporting and recording requires immediate review so that the provider complies with health and safety legislation and so that there is a clear audit trail of information. 31/01/07 31/01/07 31/01/07 31/03/07 31/03/07 06/12/06 06/12/06 31/12/06 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA22 YA42 Good Practice Recommendations Residents case file require reorganising so that information in easy to access. To improve the quality of the pictorial complaints procedure. To keep a log of regulation 37 reported to CSCI and to keep a log of accidents. DS0000016977.V307330.R01.S.doc Version 5.2 Page 31 Westley Brook Close Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westley Brook Close DS0000016977.V307330.R01.S.doc Version 5.2 Page 32 - 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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