Inspection on 18/08/05 for 118-120 Dudley Street

This inspection was carried out on 18th August 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

118-120 Dudley Street 13/01/07

118-120 Dudley Street 29/12/05

118-120 Dudley Street 16/03/05

118-120 Dudley Street 16/03/05

118-120 Dudley Street 16/03/05

118-120 Dudley Street 16/03/05

118-120 Dudley Street 09/11/04

118-120 Dudley Street 09/11/04

118-120 Dudley Street 09/11/04

118-120 Dudley Street 09/11/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE 118-120 Dudley Street 118 - 120 Dudley Street West Bromwich West Midlands B70 9AJ Lead Inspector Patrick Wright Announced 18 August 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 Older People and 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. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 118 - 120 Dudley Street Address West Bromwich West Midlands B70 9AJ 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 580 2573 0121 525 6257 N/A Lonsdale (Midlands) Limited Ms Marie Grogan CRH with Nursing 8 Category(ies) of Learning Disability (LD) - 5 Both registration, with number Learning Disability over 65 years of age (LD(E)) of places - 2 Both Physical Disability (PD) - 8 Both Dementia - over 65 years of age (DE(E)) - 1 Both 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 5 LD, 2 LD(E), 1 DE(E) and up to 8 PD Date of last inspection 16 March 2005 Brief Description of the Service: 118-120 Dudley Street is an 8-bedded nursing home for older adults with learning and physical disabilities. The home is situated close to local shops and amenities, is near to West Bromwich town centre, and is accessible by public transport. The service offers one shared and six single occupancy rooms, a communal lounge and dining area and assisted bathing facilities. Bedrooms are not ensuite. There is a domestic style laundry and kitchen, and a garden/patio area to the rear. A lift services the first floor. A range of services are available including assistance to access healthcare facilities, various in –house and external recreational pursuits, and community inclusion. The home has its own transport. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced 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 5 hours, and was a statutory announced inspection. 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. The inspection included time spent examining documentation and records, looking at how some of the care packages had been arranged and were being delivered, and having discussions with the residents, the Registered Manager and staff. There was also a brief tour of the ground floor premises, and rear garden. The inspection was conducted with the full co-operation of the Manager and staff. The discussions and atmosphere throughout the inspection was positive and constructive. Residents appeared comfortable in their surroundings and the home presented a relaxed atmosphere. There are eight residents currently living at 118 Dudley Street. The home is registered to provide nursing care for adults with learning and physical disabilities, and other complex needs. Six of the residents were present during the inspection, but formal interviews were not appropriate. However informal discussion and conversations about daily life were appropriate, and some of the occupants of the home were willing to participate. Other information was gathered prior to the inspection, which included the pre-inspection questionnaire, feedback from relatives, and some residents filled in a questionnaire. Residents who were observed/spoken with during the inspection appeared satisfied with the quality of care provided. Overall the home has a comfortable and relaxed atmosphere. The inspector would like to thank staff and residents for their co-operation and hospitality during this visit. What the service does well: 118-120 Dudley Street offers a specialised service to people (including some younger adults and older persons) with Learning and physical disabilities, and other needs. The homes certificate of registration accurately reflects the primary care needs of those accommodated. The home provides nursing care through a group of staff who collectively and individually have the skills and experience needed, and through this inspection process it was identified, communicated with residents in a positive and friendly manner. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 6 Each resident’s file provides comprehensive, individual plans of care incorporating specialist requirements and procedures designed to meet the needs of the person. All residents are fully risk assessed in a variety of activities and topics according to their individual abilities. The home uses a generic risk assessment system with interventions and guidelines for staff clearly described. Residents are provided with a positive lifestyle, including social inclusion, which strives to promote ordinary living, in an open and inclusive environment. Observations of staff and review of documentation showed that staff had identified clear working relationships with each other, and this transcribed into continuity of care in terms of meeting individuals specialist needs. At the time of the inspection staff within the home had the capacity to meet residents assessed needs. Residents and relatives all offered positive comments about the service. Residents said they liked living at the home, were well cared for and the staff treated them well. They also said they chose what they eat, could have visitors, and felt safe at the home. One person said “I like the place” and “ I like everything”. One relative said “ My relative is well looked after and is always happy” and my relative is exceptionally well cared for” What has improved since the last inspection? What they could do better: The service needs to progress with a Person Centred planning system of care and for example, develop Lifestory books with residents. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 7 The Manager should consider reviewing the office filing system, streamlining the documents held and archiving relevant records no longer used on a daily basis. The Manager must review the level of supernumerary time available to address administration and other management tasks. The system for monitoring the healthcare needs of the residents must be kept up to date and the information summarised on a checklist, must relate to supporting information in each persons file. The Manager needs to produce more detailed `falls risk assessments` for older adults and also with regard to a continence assessment for one of the residents. The company must ensure that all unwanted items and debris is removed promptly, and the area kept safe during the building works, this ensuring the external recreational space is kept free of hazards. The home requires additional storage for equipment and aids, which should be of a good standard and fit for the purpose. 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. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Prospective residents of the home are assessed appropriately to determine whether the home is suitable for them, and whether it can meet their needs. EVIDENCE: There have been no new admissions to the home since the last inspection. However, the home uses a needs assessment system, which is detailed and contains relevant points to determine if the home is suitable for the individual and can meet his/her needs. This was examined on three residents files. Care Management documentation is also secured for new admissions from the placing authority, and was available. New residents are admitted only on the basis of a full assessment, (using the tool above which covers the areas in Standard 3.3 National Minimum Standards/Older People). For residents who have lived at the home for some time, assessments should be regularly reviewed/updated, at least annually. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 The home has a detailed care planning system in place to provide staff with the information they need to satisfactorily meet the residents needs The health needs of residents are being met with some evidence of multi disciplinary working taking place. However, further work is needed to ensure supporting information is available and healthcare assessments are all completed. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 11 EVIDENCE: Each resident’s file contains a series of care plans, which varied in number and content dependent upon the needs of the individual. Through case tracking it was identified that care plans were available for each area of identified need. The service user plans are being reviewed in the home at least once a month. Reviews of service user plans offered sufficient detail to suggest the changing needs were being monitored. One service user commented “All is good” It was identified that one of the residents is increasingly displaying challenging behaviour. The Manager was told this must be recorded in the care plan, risk assessment and daily notes and the potential training need raising with the organisation. The home needs to demonstrate that the care plan is drawn up with the involvement/agreement of the service user, and/or signed by a representative. The home should progress with the implementation of a system of Person Centred Planning or similar such as Essential Lifestyle Planning or Life Story books. Evidence available in files to indicate that residents health care needs are being met is not detailed enough. It was found to be dispersed amongst the documents held in the office. The Manager told the inspector that details of appointments past and in the future are recorded in the diary. Some evidence of correspondence such as G.P, Consultant Psychiatry and community nursing/health professionals consultation was identified, but this was not always collated and there is a risk that a routine appointment or otherwise may be overlooked. The `OK` health checklist is being implemented to support the healthcare plans, but those seen had gaps in the entries which do not support the anomalies found in other records. The system for monitoring the healthcare needs of the residents must be kept up to date and the information summarised on a checklist, must 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. Equipment for the promotion of tissue viability is being utilised, and risk documents with regard to pressure area care are maintained. Nutritional screening is routinely undertaken, and assessments were seen on each of the service users files. Service users weight is monitored. The manager was told of the need to explore and produce more detailed falls risk assessments for older adults and also with regard to a continence assessment for one of the residents. The Registered Manager was told that from April 1st 2005 a new NHS contract for community pharmacists was introduced. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 12 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. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The meals in this home are good, and service users are offered choices and a balanced diet. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 14 EVIDENCE: Residents at Dudley Street continue to be offered a variety of meals taken from a menu produced in consultation with residents, and based on their likes/dislikes. Menus are produced on a weekly basis through consultation with the occupants of the home. Menus offer drawings to accompany the written information, and a pictorial menu guide to assist service users with communication needs to make an informed choice, is being produced. Regular meals, snacks and hot/cold drinks are available. Meal planning is flexible, and can be changed, as needed/requested. There were some gaps in the recording of core cooked temperatures, which should not be happening as most of the staff team have been provided with Basic Food Hygiene training. Observation made during this visit confirmed that the serving of meals is not at `set` meal times and it was noticed residents were given time to eat, were not hurried and staff were available for assistance when necessary. It was also noticed that residents were given a choice as to where to sit and eat. Two residents were taking `brunch` after getting up from sleep at a time to suit themselves. This demonstrates that choice and flexibility is available at this home. One of the residents stated “ I can go out on outings, and I have my own room which I can go to when I want”. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 There is a clear complaints procedure for residents and relatives, thereby ensuring individuals views and concerns are listened to and acted upon. Arrangements for protecting residents from harm or abuse are satisfactory EVIDENCE: 118 Dudley Street operates Lonsdale Midlands Ltd complaints procedure and records will be kept of any complaint or issues raised. No formal complaints had been received at the time of inspection. The complaint procedure contains details of the Commission for Social Care Inspection, and the procedure is available to residents and their 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 that has been referenced to the Department of Health guidance ‘No Secrets`. This policy has been brought to the attention of all staff, previously through a staff meeting and briefing session. Training in Adult Protection issues has been provided for the majority of staff, and some certificated evidence was available in the sample of staff files examined. The home has copies of the Department of Health guidance ‘No Secrets`, and the local Sandwell Vulnerable Adults Procedure. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 16 The Manager was told of the need to explore the use of advocacy services for two residents with regard to their wishes about specific issues around finances. One of the residents commented “ I Like the people I live with”. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) nil Not applicable- no standards from this section were assessed EVIDENCE: It was noted that the extension to provide two refurbished bedrooms with ensuite facilities for two existing residents was in progress. One of the residents commented “ It’s a smart house”. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 This home offers a good match of qualified and support staff offering consistency of care to residents. The standard of vetting and recruitment practice is satisfactory with the appropriate checks being carried out, thereby not placing residents at risk. EVIDENCE: Examination of staff files found the records required, including references, statements of health and declaration of convictions, criminal record bureau checks etc. Staff have been issued with the General Social Care Council (GSCC) Code of Conduct. Files examined were well organised and meet the requirements of the Care Homes Regulations 2001. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 19 The home provides in excess of the minimum staffing numbers as recommended by the Department of Health, but this is required due to the service offering specific packages of care, which include/require a higher ratio of staffing levels to meet the assessed needs of the residents. Staffing levels were seen to be appropriate at the time of inspection. The service operates with one qualified nurse and three support workers on duty during the waking day and one qualified nurse and one support worker on wakeful night duty. The manager continues to monitor staffing levels at the home against the assessed needs of the service users whose dependency levels are increasing due to age and mental capacity. The home has recently appointed two qualified staff (Deputy Manager and Assistant Home Leader). The Manager works `long day` shifts over three and a half days, and has been working as the nurse in charge. The opportunity for supernumerary time for the Manager should be revisited as this has been lacking for some time, and may account for the slippage in maintaining administration records etc. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 37, and 38 Residents financial interests are safeguarded by the policy and practice within the home. The manager is seen to ensure as far as reasonably practicable, the health, safety and welfare of residents and staff. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 21 EVIDENCE: The homes policy and practices regarding residents’ money/financial affairs are managed appropriately, and suitable storage facilities are available for money/valuables. A new safe has been provided. Written records of residents’ money/transactions were seen to be maintained appropriately. Money is held separately, (not pooled), in secure facilities with restricted access by senior staff only. Receipts were available for items/monies in safekeeping. Expenditure records and balances are examined and had 2 witness signatures, were checked daily, and balances are the subject of handover checks by staff. The manager is not agent or appointee for any service user. A random sample of maintenance, service records and other documents were examined, and were all found to be available and current. The standards were satisfactory, but not as well maintained as at previous inspections. One recent incident which resulted in a resident being admitted to hospital should have been reported to the Health and Safety Executive, (under `RIDDOR`) and the Manager was told to report the accident as soon as possible. Personal inventories of residents’ belongings and items of value must also be held and maintained appropriately. Residents’ files must contain a current record of belongings with dates of receipt and disposal, if relevant. One of the residents said “ there is nothing I would like to change”. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 x 2 2 3 x 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score x x x x x x x x Score Standard No 7 8 9 10 11 Score 2 2 x x x Standard No 27 28 29 30 2 x 3 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 x 34 x 35 3 36 x 37 2 38 2 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 23 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 need to incorporate the physical environmental standards of the home, i.e., communal and bedroom sizes, identifying any rooms failing to meet National Minimum standards. (previous timescale of 31/5/05 not met) For existing residents (who have lived at the home for some time), assessments should be regularly reviewed/updated, at least annually. The homes care planning system should incorporate all areas of need, including challenging behaviour, and staff receive suitable training in the subject The home should progress with the implementation of a system of Person Centred Planning or similar such as Essential Lifestyle Planning or Life Story books. (Previous timescale of 30/7/05 not met) 1) The system for monitoring the healthcare needs of the residents must be kept up to date and the information summarised on a Timescale for action 31/12/05 2. 3,4 14 31/12/05 3. 7,30 15,18 31/12/05 4. 7 15 31/12/05 5. 8 12,15 1) 31/12/05 2) 30/9/05 Page 24 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 6. 9 13,16,17 7. 19 13,23 8. 27,31 9,12,18 9. 37,38 17 checklist, must relate to supporting information in each persons file. 2) The Manager needs to produce more detailed falls risk assessments for older adults and also with regard to a continence assessment for one of the residents. 1) To ensure that the room temperature of the medication and Oxygen storage area is monitored and recorded, and is kept below 25 degrees Celcius. (Previous timescale of 30/4/05 partly met) 2) 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. The company must ensure that all unwanted items and debris is removed promptly, allowing staff to ensure the external recreational space is kept free of hazards. Increased safety measures should be provided around the pond. The home requires additional storage for equipment and aids, which should be of a good standard and fit for the purpose. (Previous timescale of 30/6/05 not met) The Registered Manager must be furnished with adequate supernumerary time off rota, to address the managerial and administrative aspects of the role 1) A inventory of personal possessions must be provided for each service user, and be kept up to date as possessions are 1) 30/9/05 2) 31/10/05 30/11/05 30/11/05 1) 31/12/05 2) with immediate Page 25 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 added or removed. 2) The Manager must ensure that all relevant accidents (under RIDDOR) are brought to the attention of the Health an Safety Exexcutive effect RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 18 28 31 37 Good Practice Recommendations The Manager should explore the use of advocacy services for two residents with regard to their wishes about specific issues around finances. 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 31/12/05. That the Manager is registered and is working toward an NVQ IV in Management by 30/9/05, to be achieved by 30/9/07 The Manager should consider reviewing the office filing system, streamlining the documents held and archiving relevant records no longer used on a daily basis 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 26 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. 118-120 Dudley Street DE55 S4771 118-120 Dudley St V237474 18-0805 Announced Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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