Inspection on 05/07/05 for 1-5 New Street North

This inspection was carried out on 5th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

1-5 New Street North 21/01/08

1-5 New Street North 02/04/07

1-5 New Street North 08/01/07

1-5 New Street North 01/06/06

1-5 New Street North 17/01/06

1-5 New Street North 23/03/05

1-5 New Street North 02/12/04

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 08/07/2008.

CARE HOME ADULTS 18-65 1 - 5 New Street North 1 - 5 New Street North West Bromwich West Midlands B71 4AQ Lead Inspector Patrick Wright Unannounced 5th July 2005 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 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 Stationary 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. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 1 - 5 New Street North Address West Bromwich West Midlands B71 4AQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 553 1755 0121 553 4254 N/A Lonsdale Midlands Limited Mr Nicholas Doyle CRH 8 Category(ies) of Learning Disability (8) registration, with number of places 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Not Applicable Date of last inspection 23rd March 2005 Brief Description of the Service: 1-5 New Street is a nursing home for 8 service users who are learning disabled and require additional support due to presenting behaviour that may challenge. At the time of this inspection the occupants of the home were younger adults. The proprietor of the home is Lonsdale Midlands Ltd, and the service was first registered by Sandwell health authority in June 2001 The home comprises of 8 single rooms, a domestic style kitchen, 2 bathrooms, laundry, 2 lounges, an activity area, sensory room and a dining area. A lift services the first floor. Entrance to the home is via a coded door lock at the front, leading to the porch area. The home is situated on a slip road just off the main road adjacent to Dartmouth Park in West Bromwich. West Bromwich town centre is within walking distance and parking space is available at the front of the home. There is a lawned area to the front of the building and a small patio area located to the rear. The service has its own transport and regularly accesses local facilities. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over 4 hours, and was a statutory unannounced inspection of the service. The purpose of the inspection was to assess progress and compliance in meeting the National Minimum Standards and towards addressing items identified at previous inspection visits. A range of inspection methods was used to make judgements and obtain evidence, which included discussion with the qualified nurse in charge at the time, and a brief tour of parts of the premises, and rear patio area. Service users bedrooms were not seen on this visit. Service Users were involved in various community activities during the inspection. Three of the service users were present for part of the inspection, but formal interviews were not appropriate. Therefore the inspector relied upon observations of body language, eye contact, gestures, responses and other observations of interaction between staff and service users. A number of records and documents were also examined. Service users appeared comfortable in their surroundings and the home presented a relaxed atmosphere. The Registered Manager of the service was off duty when this inspection took place. The inspection was conducted with the qualified nurse in charge who is fully involved in the day-to-day running of the home. There are seven service users currently living at 1-5 New Street. There is one vacancy, which has been available for several months. Based on the information available to the inspector at the time of this visit, it is only possible to evidence in part, that services offered were meeting the needs of the people who live there. However, the home does provide a stable environment and staff interacted well with service users. The service has remained `stable` since the last inspection, but there is little evidence of any innovation at the home or desire to rise above what is considered to be a minimum standard. What the service does well: Staff appear caring and supportive of service users. The home regularly accesses the local community to meet the social and educational interests of the occupants of the home. The home manages situations which can be described as very challenging and there is a fairly stable staff team to support the service users through this. In addition there is a risk management system that covers numerous areas within the scope of the service. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 6 Relatives and friends are encouraged to maintain links with the service users and are welcome to visit at any reasonable time, and the company complaints procedure is readily available should anyone wish to use it. The organisation manages to address the fabric of the building to a satisfactory standard given the wear and tear it endures from the active group who live there. What has improved since the last inspection? What they could do better: Following each inspection of this service, an action plan is submitted to the Commission for Social Care Inspection, which usually indicates that the service is working toward compliance. However, at subsequent visits it is identified that the home is maintaining a status quo, or `coasting`, often with additional requirements being issued, rather than fully meeting its previous requirements. The home could do better in demonstrating it provides a `needs led` service to its residents and include in daily reports and records examples of how service users are offered real choices on an individual basis which reflects their preferences. There is little `drive` to raise and maintain standards and expand the delivery of care. This may be frustrating for those who live and work within the home that want to develop, be creative and innovative and demonstrate that the home is delivering what it claims to deliver in its publicity information. The home must also do better with regard to food hygiene and safety issues which are potentially putting people at risk. In addition, the implementation of a person centred planning approach is paramount to the ongoing development of the service. This should be incorporated within the Annual Development plan for the service, detailing the aims and planned outcomes for service users and the staff team. The annual development plan was not available at the inspection, and remains an outstanding issue. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 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. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 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 standard(s) 1, 2 and 3 The homes Statement of Purpose and Service User Guide although adequate, does not accurately present or reflect the services the home provides, or to encourage prospective service users. The needs assessments are not being kept under review to ensure the service is the right one for people who live there. EVIDENCE: The home has a Statement of Purpose and a Service User Guide, which has been issued to existing service users, and is held on their personal files. A statement of terms and conditions is also supplied. It is required that the above documents are reviewed, as is required under the Care Homes Regulations (Regulation 6) to ensure they reflect the level of services that the home claims to provide. Consideration should also be given to the format of these documents, which could be more imaginative and include pictures and photographs etc to allow the prospective placing authority and service user to assess whether the home meets its Statement of Purpose. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 10 The home continues to use the `Activities of daily living skills` assessment tool. Copies of relevant `Care Management` documentation from social workers/community nurses was seen on a sample of files, and the home uses the information to produce service user plans. For prospective service users the home intends to conduct an assessment based on the ‘Activities of Daily Living’ model. At the last inspection the manager was in the process of updating assessments and had chosen to use the `Pathways to Independence` assessment record, after difficulty in identifying a suitable assessment tool for the client group. Work remains outstanding on this subject to ensure service users needs are periodically reviewed. Some evidence of review was located on files but this seems to have been instigated by the placing local authority rather than the home. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 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 standard(s) 6, 7 and 9 There is an adequate care planning system in place to provide staff with the information they need, but the system does not progress to a person centred approach. However, there is little evidence of strategies in place to evidence that service users rights to make decisions, choices and exercise control are encouraged. EVIDENCE: At the time of the inspection a selection of care plans were reviewed as part of the case tracking process. Each service users’ file provides basic individual plans of care incorporating procedures designed to meet the needs of the person. The records were being reviewed as dated but should also advise as to any significant professionals involved. There was no consistent evidence that the care plans are compiled/vocalised with the service user, and/or their representative. The plans examined were dated and the name of the nurse compiling the plan was printed. The format of the care plans is standard English print and there needs to be more thought into how this can be made more informative for service users. The home is not implementing a system of Person Centred Planning or similar such as Essential Lifestyle Planning. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 12 The entries in daily notes and nursing notes do not show how staff are respecting service users rights to make decisions and if any rights are restricted, how this has been agreed and is being managed. Similarly, the manager must consider strategies for demonstrating how individual choices have been made and why, when such choices are made by staff. At the time of the inspection a random selection of risk assessments were reviewed. On examination of this documentation it can be confirmed that the home has an acceptable risk assessment process. Service users are risk assessed in a variety of activities according to their individual abilities, e.g. community presence, household management, and behaviour management. Those examined did suggest they could be referenced to elements of the service users needs assessment. The documentation in personal files (Care management plans and risk management) relating to Non violent Crisis Physical Intervention or NVCPI techniques, serves little purpose as several staff have not attended the foundation training and those who have attended are well overdue for refresher/updates. Staff and service users are being exposed to unnecessary risks due to this lack of action. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 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 standard(s) 15, 16 and 17 Staff support service users to maintain relationships inside and outside the home, but other issues such as individual choices and influencing daily routines is not evident. The meals in this home are poor with little evidence that service users are offered either quality meals or choice. EVIDENCE: The home has a visitors’ policy, which has been brought to the attention of the service users relatives /friends. There are details regarding visiting times contained in the policy, which states there is generally open visiting. There is a visitor’s book in the office that all visitors are asked to sign, which is good practice and complies with fire safety. Staff encourage service users to maintain contact with family and friends. Visitors are welcome and service users have opportunities to meet new people through the local community, and activities. Contact with relatives varies between service users, but links are maintained to whatever degree compatible for both parties. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 14 Menus are prepared each week, and the menu sheet for the week of this visit indicated that an alternative choice for each main meal is on offer. The meals are said to be based on the known likes/dislikes of the service users. This was explored further with the nurse in charge. However the offer of a choice was not a realistic one. It was not possible to support the claim that service users likes etc have been incorporated into the plan and the reality of being served an alternative was unlikely as most of the service users are not being enabled to make a decision about this, with assistance in the form of a comprehensive pictorial menu or for example, taster sessions of different foods. The variety of foods being served does not offer a balanced diet. Whilst service users have a right to eat the foods they prefer, the home has a responsibility to offer and encourage a varied diet. Meal plans include the same foods repeated and sometimes for each meal, i.e. cheeses, red meats, or pasta and include convenience meals, with little evidence of fresh fruit or vegetables. Staff should also be reminded of the need to keep records of variations/alternatives to the planned menu, as these were not apparent. Staff are not checking the core temperature of foods to be served and there are major omissions in the records of cooked food temperatures. In addition fridge and freezer temperatures are not consistently being checked and recorded. Most staff involved in the preparation and cooking of food have attended a basic food hygiene course, but despite this action has not been taken by the management to ensure this issue has been addressed. The management of food safety within the home is poor. Bottles and packets etc of foods were found to have be opened, not labelled with the date of opening or expiry, not refrigerated as appropriate and the standard of hygiene in some of the food storage cupboards was inadequate. Refuse bins in the kitchen area should have lids fitted that can be opened without handling the bin itself. The dishwasher should also be replaced or repaired. It is noted the kitchen worktops have been replaced as required previously. Privacy locks are fitted to service users rooms and the use of keys by service users who accept the offer is the subject of a risk assessment. Service users are not offered keys to the front door, as the home is rarely unattended, and due to suggested security risks has a coded door lock fitted. Service users have unrestricted access to the home with the exception of the kitchen, laundry, and staff room/office. The home to needs to consider how it can ensure it is able to demonstrate that service is as flexible as possible in terms of general routines of daily living. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 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 standard(s) 19 The health needs of service users are being met with evidence of multi disciplinary working taking place. However, further work is needed to ensure supporting information is available and healthcare assessments are all completed. EVIDENCE: There was evidence available to indicate that generally service users healthcare needs are generally being met. Service users are registered with a local GP and links were being maintained with the service users Consultant Physiatrist. Documentation relating to other services such as ophthalmic, dental and chiropody services was available, as was other healthcare services/specialists. Service users health is monitored within the home as well as undertaking individual weight checks. Support is provided to access a range of healthcare facilities, and attend outpatient and other appointments. The information with regards to healthcare is summarised on a checklist, which provides a reference tool for tracking the appointments for service users. This information must however relate to supporting information in each persons file. On this occasion it was not always possible to reference the checklist to the correspondence in the files possibly due to the amount of information held. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 16 The Registered Manager is advised that from April 1st 2005 a new NHS contract for community pharmacists was introduced. Effective immediately, care homes (nursing) are prevented by law from returning waste medicines to a community pharmacist. Arrangements must be made with a licensed waste management company, as required for other clinical waste. Therefore community pharmacists cannot accept medication waste from care homes (nursing only), unless their pharmacy holds a Waste Management Licence. This must be explored with the community pharmacist and records be maintained of the system in place, for the purpose of inspection. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 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 standard(s) 22 and 23 There is a clear complaints procedure for service users and relatives, thereby ensuring individuals views and concerns are listened to and acted upon. Arrangements for protecting service users through staff training and awareness could not be confirmed. EVIDENCE: 1-5 New Street operates Lonsdale Midlands Ltd complaints procedure and records will be kept of any complaint or issues raised. No formal complaints had been received since the last inspection. The complaint procedure contains details of the Commission for Social Care Inspection, and the procedure is available to service users and representatives, in appropriate formats. The company’s complaints procedure details how to make a complaint, to whom and the timescales involved. The organisation has an Adult Protection policy, which has been referenced to the Department of Health guidance ‘No Secrets`. It was not possible to confirm if this policy has been brought to the attention of all staff, or if training in Adult Protection issues has been provided. The homes policy and practices regarding service users money/financial affairs was not examined at this inspection. It was noted that a new safe has been provided for the safekeeping of monies and valuables. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 The premises are clean and improvements have been maintained to the infection control measures being exercised by staff. EVIDENCE: 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 19 At this inspection, the home was in places clean and tidy. The parts of the home that were viewed, were home found to be free from odour. Laundry facilities are appropriate, sited in a separate area designated for the purpose and do not intrude on residents routines. Washing machines have a specified programme to ensure certain laundry is washed at appropriate temperatures, has the appropriate sluicing facilities and walls, floors and the ceiling in the area are washable. A hand-washing facility is available although this is also the sink for filling mop buckets etc and consideration should be given to installing a separate had – washing sink. Liquid soap, paper towels (for which a dispenser is needed) and disposable aprons and plastic gloves are available. Mops and buckets are labelled and colour coded for different areas of the home and the storage of substances that may be hazardous to health (i.e. cleaning products etc) is acceptable. Training for staff in Infection Control measures was not analysed at this inspection. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) nil No standards from this section were fully assessed as part of this inspection EVIDENCE: It was concerning to note that the level of staff sickness in recent months has increased which impacts on remaining staff, and should be monitored closely for any patterns and to ensure staff are being supported appropriately with training and supervision sessions. It was not possible to access staff personnel records at this inspection. The nurse in charge stated that the manager and deputy manager had keys to the storage facility, which holds such records. It was stated the storage facility had been moved to the first floor but on further examination the records were not located there and it was unclear as to where they were held. Even so staff personnel, training and development, supervision records must be available for inspection at all times as required under Regulation 17 3 (b) of the Care Homes regulations 2001. It was of particular concern that a previous requirement to provide staff with training in the management of behaviour that challenges has not been provided. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 21 It was stated at the last inspection that some staff needed to be provided with the (NVCPI) training and for existing staff to attend updates, as some had not attended an update since the initial training over 2 years previously. This training is essential given the behaviours displayed by the client group at the home and the risk of challenges staff encounter on a regular basis. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) nil No standards from this section were assessed as part of this inspection EVIDENCE: During the inspection 3 service users files were examined which identified that personal inventories had not been maintained and were out of date. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 2 x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 1 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x 3 x 1 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1 - 5 New Street North Score 2 2 x x Standard No 37 38 39 40 41 42 43 Score x x x x 1 x x E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 6 Requirement The Statement of Purpose and Service User Guide must be kept under review and should accurately reflect the services provided Service Users needs assessments must be kept under review and revised at any time/ as part of a multi agency approach with other professionals The registered person must demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home, and to further demonstrate it offers care based on current good practice and reflects relevant and clinical guidance.(previous requirement from 23/3/05 not met) 1)To reproduce care plans in a format suitable for service users. 2)To ensure daily reports reflect goals identified in care plans. 3)To introduce effective evaluation, monitoring and reviews of service users plans which must be sufficiently detailed to reflect the changing E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Timescale for action 31/10/05 2. 2 14 31/10/05 3. 3 14 30/11/05 4. 6 15 1),2),3)30/11/05 4) 31/8/05 1 - 5 New Street North Version 1.40 Page 25 5. 8,7 12 6. 12 12,16 7. 13 16 8. 16,18 12 needs of service users, and the objectives set. (previous timescale of 31/7/05 not met) 4)Ensure that the care plans are compiled with the service user and/or their representative, and are dated/signed.(previous timescale of 31/8/05 remains) 1) To demonstrate ways in which service users are involved in the day to day running of the home and are consulted on issues affecting the service provision. 2) To further demonstrate how routines within the home are flexible and service users are enabled to exercise control (previous requirement of 23/3/05 not fully met) 3) Staff to demonstrate how individual choices have been made and record instances when decsions have been made by others and why (previous requirement of 23/3/05 partly met) To ensure individual activity plans are produced with regards to day care, which are up to date and wholly reflect residents’ needs and wants. To ensure that activities are fully evaluated (previous requirement of 23/3/05 partly met) To ensure that service users enjoy a wide range of stimulating social activities including participating in the community and evidence is available (previous requirement of 23/3/05 partly met). The home must demonstrate how daily routines and house rules promote independence, individual choice and freedom of movement, and are subject to restrictions only as agreed in the individual Plan and Contract 31/10/05 31/10/05 31/10/05 31/10/05 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 26 9. 17, 42 13,16, 23(5) 10. 18 12 (previous requirement of 23/3/05 partly met). 1) The home must ensure it is able to effectively evidence that service users have real choices with regard to food and meals 2) To ensure that written records are maintained of consultation with service users when the alternatives are provided from the main menu 3) To ensure that the home provides adequate, wholesome and nutritious food which is properly prepared 4) That all high risk products are labelled with the date of opening (for example sauces, mayonaisse) and frozen foods are labelled with the date of purchase or freezing 5) Staff must routinely and consistently record the core temperature of cooked food for each relevant meal taken by service users (previous timescale of immediate effect not met) 6) Consistent records of fridge & freezer temperatures taken must be maintained (previous timescale of immediate effect not met) 7) The dishwasher should be repaired or rplaced 8) Refuse bins in the kitchen and laundry areas should have lids 9) That overall the Manager makes suitable arrangements for maintaining satisfactory standards of hygiene, if appropriate after consulatation with the Environmental Health Authority Individual working records should clearly set out residents preferred routines, likes/dislikes etc (previous requirement from 23/3/05 partly met) 31/8/05 31/10/05 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 27 11. 19 12 12. 20 13 13. 23 13,18 14. 24,28 23 15. 34,35,36 17,18,19 Supporting information/evidence must be available in each residents file for tracking information from the healthcare matrix of appointments etc 1) Staff signatures for the homes medication policy and of staff that administer medication to service users must be updated (previous timescale from the 23/3/05 not met) 2) Consent to medication needs to be further explored and involve relatives/representatives of service users (previous timescale from the 23/3/05 not met) 3) The manager must ensure that the homes chosen community pharmacist holds a Waste Management Licence for the disposal of unused medications or alternative arrangements are made with a Waste Management company. Certificated evidence for all staff that have been provided with training in Adult protection is required to be held on staff files (previous requirement from 23/3/05 not able to be assessed) 1) The outdoor space at the home should be developed and appropriately maintained to incorporate a safe and pleasant environment for service users to utilise (previous timescale of 30/6/05 not met) 1) The registered person shall ensure that the records referred to in Schedule 2 and 4 of Regulations are at all times available for inspection in the care home by any person authorised by the Commission 2) To ensure that induction (within 6 weeks of commencement) and foundation 30/9/05 1),2)31/10/05 3) 30/8/05 31/10/05 31/10/05 1) 31/7/05 2),3)31/10/05 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 28 16. 35 13, 18 17. 37 9 18. 39 24 19. 41 17 training (within 6 months of commencement) is delivered, and is in accordance with guidance issued by the National Training Organisation (NTO) (previous requirement from 23/3/05 not able to be assessed) 3) To ensure that relevant staff are registered on a `Learning Disability Award Framework` accredited training course (previous requirement from 23/3/05 not able to be assessed) Staff must be provided with appropriate physical intervention and challenging behaviour management training (for example, NVCPI). Existing staff must be given updates (previous timescale of 31/5/05 not met) The Registered Manager must demonstrate strategies for management planning and practice, which encourages and rewards innovation, creativity, development and change (previous requirement from 23/3/05 not met) To produce an Annual Development plan, which is based on a systematic cycle of planning-action-review and reflects the aims and outcome for service users (previous timescale of 30/4/05 not met) A inventory of personal possessions must be provided for each service user, and be kept up to date as possessions are added or removed 30/9/05 31/10/05 31/10/05 30/9/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 29 No. 1. 2. 3. Refer to Standard 6 17 20 Good Practice Recommendations The home should begin to consider how it can implement a system of Person Centred Planning or similar, such as Essential Lifestyle Planning or Life Story books. Menus could be made available in different formats with pictorial options produced using photographs to assist service users to make a choice. It is recommended that the home adopts a Monitored Dosage system for the management of service users medications to enable the qualified staff team to focus on the production of records, in developing a person centred approach, and in further demonstrating the home has the capacity to meet the assessed needs of the service users. a) The organisation should consider installing a handwashing sink in the laundry area rather than staff use the same sink for waste and mop buckets b) A paper towel dispenser should be fitted in the laudry room That the home continues to work toward meeting Sector skills workforce targets of 50 of care staff having achieved an NVQ level 2 or above by 2005. The manager should monitor sickness levels within the same team and ensure relevant action is taken/support offered and systems are in place to ensure remaining staff do not work excessive hours to cover shortfalls That the Manager continues to work toward an NVQ IV in management 4. 30 5. 6. 32 33 7. 37 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 30 Commission for Social Care Inspection Mucklow Office Park West Point 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 1 - 5 New Street North E55 S4798 1-5 New Street Unannounced V237169 5-7-05 PW Stage 4.doc Version 1.40 Page 31 - 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!