Inspection on 16/02/06 for 18 Clive Street

This inspection was carried out on 16th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

18 Clive Street 03/07/07

18 Clive Street 13/07/06

18 Clive Street 21/07/05

18 Clive Street 28/01/05

18 Clive Street 26/04/04

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 18 Clive Street West Bromwich West Midlands B71 1LH Lead Inspector Jayne Fisher Announced Inspection 16th February 2006 09:30 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 18 Clive Street Address West Bromwich West Midlands B71 1LH 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) 0121 553 7251 Calanmill Caring Services Millicent Bedworth Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21 July 2005 Brief Description of the Service: 18 Clive Street provides a homely and caring environment for three adults with learning disabilities. It is situated in a residential area of West Bromwich within walking distance of many local amenities.The Home provides a unique service as it was set up in order to provide care specifically to meet the existing client group. The Registered Provider states that it is unlikely that any new service users will be admitted should any future vacancies arise. The environment which is rented from the Local Authority is well maintained and communal areas consist of lounge, dining room, kitchen and garden. There are toilet facilities on the ground and first floor. Service users bedrooms and bathroom is located on the first floor. Service users are encouraged by staff to participate in daily household tasks. They are also encouraged to maintain and develop a wide range of social interests outside the home. Arrangements are made by the home for service users to enjoy regular holidays throughout the year. Service users attend various college and day placements during the week, depending on their individual needs and interests. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted between the hours of 9.30 a.m. and 3.00 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: case tracking, interviews with the registered manager who is also the owner, the responsible individual and a visiting relative. There was also a tour of the premises. One of the three residents was at home during the inspection. They were happy to participate and showed the inspector around their home. A number of records and documents were examined. Other information was gathered prior to the inspection from an action plan submitted by the manager following the last inspection and a pre-inspection questionnaire. Four relatives/visitors completed feedback questionnaires. 18 Clive Street provides care for three adults who have learning disabilities. All residents are self advocating and require varying levels of support. A number of standards were examined at the last inspection and this report should therefore be read in conjunction with the previous inspection report to give a comprehensive overview. The inspector was made to feel very welcome and would like to thank the service user, management and staff for their assistance and co-operation during the visit. What the service does well: Staff provide a service to residents which is very much tailor made to meet their individual preferences and requirements. For example residents are not forced to attend external day centres and one resident has recently elected to spend an extra day at home. All residents enjoy an active social life and participate in a wide range of leisure pursuits within the local community. Residents take responsibility for helping out around the home and undertaking household chores. There is no fixed menu, instead residents go food shopping and choose ingredients and meals they would like to eat over the forth-coming week. The manager carefully monitors residents’ health care so that any problems are quickly identified and active treatment is sought. There is a comprehensive complaints system so that both residents and visitors know who they can approach if they are unhappy. The home is decorated and furnished to a good standard and provides a homely atmosphere for residents. There is a small stable staff group who assist the manager in providing support to residents. Both members of staff hold an NVQ qualification. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 6 Feedback from the resident who was at home was very positive about all aspects of care. Similarly, all visitors/relatives feedback was very positive. Comments included: “Totally satisfied with the standard of care – exemplary”. What has improved since the last inspection? What they could do better: 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. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 7 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 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 8 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): These standards were not evaluated at this inspection. EVIDENCE: Progress was monitored towards outstanding requirements. The manager still needs to update the statement of purpose with details of staff mandatory training which has been undertaken. The terms of conditions of occupancy still need further amendments as identified at the last visit in order to comply with the requirements of the National Minimum Standards 5.2. The home is fully occupied and is unlikely to accept any new admissions should a vacancy occur. There is an outstanding requirement to ensure that existing residents receive a periodic reassessment of their needs in order to ensure that care plans are up to date and reflect any changes. This has yet to be undertaken. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 9 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): 7 Residents are fully encouraged to make decisions and are supported to do so if required, by staff. EVIDENCE: Progress was monitored at this visit towards outstanding requirements in relation to care planning and risk assessments. Care plans still need to be expanded in some areas where increased support is required, or to reflect changing needs. For example one resident has recently been unwell and has a poor appetite. Investigations are on going and as advised by the hospital the manager has introduced a high fat diet. None of this is reflected in the care planning system. Another resident has gained weight and is following a healthy eating plan which is not indicated in a care plan. Although the manager has attempted to improve risk assessments, these ultimately remain a basic description of need. As previously identified risk assessments are confusing and do not contain the level of information required. For example, one risk assessment contained a number of risks including crossing the road, the use of electrical equipment, bathing and use of the cooker. It was not clear what control measures are in place for each risk (as they will be different for each one). Separate risk assessments must be 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 10 carried out for every potential risk identified. Information must include who is at risk (this could be either service users and/or staff), the level of risk (high, medium or low), the control mechanisms in place and any extra precautions necessary. All risk assessments need to identify an actual date of review. It is recommended that the manager receives training in risk management in order to understand the principles of this concept and introduce meaningful risk management strategies into the home. All residents are able to express their preferences and in some cases are self advocating. Extra support is given as and when needed by the manager and staff with regard to decision making. Residents have access to advocates if required for example Local Authority appointees and a Solicitor who manages a trust fund. Service users need varying levels of support in managing their finances. It is commendable that the manager supports residents to maintain their independence with regard to control of their finances. During interviews one resident spoke about how she enjoyed spending her money on buying clothes. At previous inspections it has been required that care plans are established in order to describe the level of support given by staff. This is still outstanding. See standard 23 for further comment. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 11 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 Service users are given ample opportunities to maintain and develop social skills and enjoy a wide range of stimulating activities within the local community. Service users are fully supported by staff to maintain important links with family and friends. Residents’ daily routines are operated on the principles of choice and respect. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users’ tastes and choices. EVIDENCE: All residents attend some form of external day care provision during varying parts of the week. Care plans contain activity programmes which identify leisure and independent living skills tasks which are planned over the week. There is a comprehensive daily reporting system and central diary which demonstrates that residents enjoy a wide range of stimulating activities especially within the local community. All relatives/visitors who completed comment cards felt satisfied with the overall care provided. During interviews 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 12 one relative stated that the benefits of her relative living at Clive Street included: “she has more independence and likes going out at night. Her opinion is always asked”. A resident who was interviewed talked excitedly about her forthcoming birthday celebrations and regular visits to a holiday caravan. Staff support residents to maintain links with families and friends. All relatives/visitors who completed comment cards stated that they were made welcome by staff when visiting the home and are kept informed of important matters. A relative who was interviewed confirmed that she could see her family member in private if they wished and that in between visits, regular telephone contact is maintained. Daily routines are flexible as observed during the inspection. Residents are encouraged to undertake independent living tasks, for example going shopping for food. One resident stated during interview “I like doing my jobs, washing up and drying up”. A previous requirement to record service users’ permission for staff to open their mail has been withdrawn as the manager states that all residents take responsibility for opening their own post. Although the manager states that she has discussed with residents the option of them holding their own front door keys and bedroom door keys, the outcomes of these discussions still need to be recorded in their care plans. There is no set menu plan as residents go shopping and select what foods they would like for the forth coming week. Residents are offered choices on a daily basis. Staff were overheard asking a resident who was at home what they would like to eat for lunch. The fridge and freezer were well stocked with quality brand named food products. There was also a supply of fresh fruit and vegetables on the premises. Every effort is made to cater to residents’ individual tastes and needs. There is an outstanding requirement to complete nutritional screening tools. On examination these are still only partially completed. It was pleasing to see that the manager had recently been trying to introduce a high fat/protein for one resident with a poor appetite and weight loss. Another resident has gained weight and efforts are being made to encourage healthy eating. Further suggestions were made regarding extra nutritional supplements and seeking advice from medical practitioners. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 13 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 and 20 Staff deliver personal support in a way which residents’ prefer and need. The systems for control and administration of medication require improvement in order to offer greater protection to residents. EVIDENCE: Since the last inspection the manager has introduced recording sheets to monitor that personal care is being delivered which is a good initiative. During an interview one resident confirmed that they can go to bed at a time of their own choosing. The manager states that there is no set routine for residents’ bathing and that they will request when they want a bath. This needs to be recorded in their care plans as discussed. There are no technical aids or equipment as residents are fully mobile. Some improvements have taken place since the last inspection with regard to medication practice. For example, keys to the medication cupboard are now held in a more secure location. Copies of prescriptions are being retained and all medication returned to the pharmacy is fully recorded. All staff are currently on a waiting list to receive accredited training in the safe handling of medication and the local pharmacist has also given advice and some training. There is better recording on the medication administration record (MAR) sheets although staff must refrain from crossing out their initials if they have 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 14 inadvertently signed their initials when administration did not take place. An appropriate letter code such as ‘F’ should be entered with an explanation given on the reverse of the MAR sheet. There are some areas where improvements are still required. For example, on occasions household remedies are administered but a policy which needs to be formally ratified by the General Practitioner (G.P.), still needs to be devised. Particular care must be taken with regard to residents who are already taking medication which contains Paracetamol or whose existing medication such as Warfarin has contraindications. As previously stated all medications administered including house hold remedies and creams (which are not used on a regular basis such as Fucidine), must be recorded on MAR sheets. It is also not acceptable to use Fucidine for any other resident than for whom it is prescribed, as the manager stated that on occasions in the past she has used this for another service user. Although receipt of medication is recorded not all details are included such as quantities and strengths. It is advised that MAR sheets may be a better recording system rather than using a separate sheet. All creams and ointments must be labelled with the date of opening as explained to the manager. From time to time staff administer Controlled Drugs on a temporary basis (usually prior to medical treatment), it is recommended that a Controlled Drugs register is purchased in which to record all receipt and administration appropriately. Any other items discussed during inspection of these standards are contained within the Requirements section of this report. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 15 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 There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon. EVIDENCE: There is a comprehensive complaints system which is openly displayed in the dining room and a copy of which is contained within the statement of purpose. All relatives/visitors who completed comment cards stated that they were aware of the complaints procedure. A relative who was interviewed said that they would approach the manager in the first instance if they wished to raise any concerns, they were also aware that they could raise issues with Social Services if they desired. At previous inspections requirements have been made with regard to obtaining up to date procedures and guidelines regarding vulnerable adult abuse and this still requires attention. It was pleasing to see that one member of staff has recently received training in vulnerable adult abuse awareness. As already stated, the majority of residents take responsibility for managing their own finances and have money recognition skills. However, the manager still offers some support by assisting residents with withdrawal from cash point machines. As previously requested individual care plans must be established which confirm what type of support residents need. One resident does not have money recognition skills and requires extra help. There are no records maintained of this resident’s expenditure or receipts obtained from purchases made. It is advised that in order to protect both the resident and the manager that a recording system is devised. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The standard of the environment within this home is good providing service users with an attractive and homely place to live. All parts of the premises are clean and hygienic although suggestions have been made to further enhance infection control practice. EVIDENCE: The resident who was at home during the inspection was happy to show the inspector around the premises. All bedrooms are individually decorated and furnished, reflecting residents’ personal tastes and characters. Since the last inspection wardrobes have been securely fixed. All bedrooms have been fitted with suitable locks to provide residents with privacy if they wish. One resident’s mattress is worn and the manager states that there are plans to purchase a new bed. All communal areas are comfortably furnished and brightly lit. There were no offensive odours. A new Yale lock has been fitted to the communal bathroom. It is recommended that a pass type lock may be more appropriate. There is a small utility room adjacent to the kitchen which contains the washing machine. There is no sluice cycle but this is a facility which is not required by residents. The manager reports that the landlord is due to 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 17 refurbish the kitchen in the near future. It is suggested that a wash hand basin should be considered as part of the refurbishment in order to improve infection control. It is also required that a supply of liquid soap is used in this area. Any other requirements or recommendations discussed during inspection of the premises is contained within the Requirements section of this report. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 18 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 and 35 Residents are supported by a small, stable, qualified staff team. Staff training and development must be given more priority in order that residents’ needs are fully met. EVIDENCE: There is a team of two support staff who work at the home alongside the manager. Both staff are qualified to NVQ II or above. A requirement has been withdrawn to undertake risk assessments for staff who work in excess of 48 hours per week, as the manager states that staff (who also have employment elsewhere), do not exceed these hours when combining both jobs. As discussed, the manager must ensure that the duty rota includes the sleeping in shift. There have been no new staff recruited since the last inspection. Staff have undertaken some mandatory training with their other employers but on examination this now require updating (see further comment in standard 42). The manager still needs to devise a training and development plan and establish individual staff training and assessment profiles. The manager has started to implement staff supervision sessions. However, on examination instead of conducting individual supervision sessions with the 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 19 two staff members, these have been undertaken collectively as a group. As discussed, these sessions should be carried out with individual members of staff in order to promote confidentiality. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 20 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 and 42 Service users benefit from a caring and conscientious manager who recognises that there are shortfalls in her knowledge and skills. Generally there is good health and safety practice although improvements are needed to ensure that residents’ well being is fully promoted. EVIDENCE: Mrs. Bedworth is both registered proprietor and manager. She set up the home in 1996 specifically to provide care for the three residents who are currently accommodated. Mrs. Bedworth has a certificate in social services which she undertook in 1986 but has not undertaken any vocational training such as an NVQ. Mrs. Bedworth works full time at the home and also provides all emergency out of hours support. The findings of this inspection confirm that Mrs. Bedworth continues to remain dedicated to providing a loving and caring environment for residents and is unflagging in her quest to ensure the needs of residents are met and the best care possible is provided. For the last few years Mrs. Bedworth has been keen to retire but has failed to recruit a suitable manager. She is aware that she has not been able to keep fully up to date with changes in legislation and best practice guidelines and by her own 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 21 admission now wishes to ‘ease back’ and work less hours. To this end she is currently actively advertising for a new manager. Advice was given at this visit with regard to the new guidance issued by the Commission for Social Care Inspection on qualifications for managers. Both the manager and two members of staff employed need to undertake mandatory training in a number of disciplines. For example, no staff have received training in infection control. One member of staff has received training in health and safety although this will be due for refresher training this year. Staff have undertaken some of the training with their other employers but the majority of this now requires updating. All staff including the manager received training in fire safety awareness in February 2005 after an Immediate Requirement was issued. This must be undertaken again in the next month. Maintenance and service records were sampled and found largely up to date although items identified at the previous inspections still require action. For example, there is no fire safety risk assessment in place, risk assessments with regard to substances hazardous to health (COSHH) also need to be established. It was pleasing to see that there are regular fire safety drills. There are up to date test certificates for electrical and gas appliances. Fixed electrical wiring has also been checked and tested within the last five years. The manager is checking the smoke alarms on a monthly basis and is required to undertake this weekly (as per guidance from the fire safety officers). It is also required that advice is sought from the West Midlands Fire Safety Officers with regard to the smoke alarms which are not interlinked and the provision of a rechargeable torch in place of fixed emergency lighting. A system needs to be devised with regard to regular testing and recording of water temperatures. Advice was given. Although staff are now checking and recording fridge and freezer temperatures on a daily basis, there is no checking of cooked food temperatures. The manager states that she has found difficulty in purchasing a food probe and advice was given. This must be given priority and the manager agreed to undertake this task. Any other items discussed during this inspection are contained within the Requirements section of this report. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 22 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 X 2 X 3 X 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 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 2 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X 1 X 2 X X X X 2 X 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 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 YA1 Regulation 4 Requirement To review and expand the statement of purpose and service user guide, for example to include staff mandatory training. (To forward a copy to the Commission for Social Care Inspection). Previous timescale of 1/9/04 is not met). To continue to ensure a system of periodic reassessment is implemented for existing service users. using a recognised/formal assessment tool, which meets the requirements of standard 2.3 of the National Minimum Standards for Younger Adults. (Previous timescale of 1/9/04 is not met). Timescale for action 01/06/06 2. YA3 14(2) 01/06/06 3. YA5 17(2) To ensure staff date and sign all assessments. (Previous timescale of 1/9/04 is not met). To provide all service users with 01/06/06 up to date statement of conditions of residency to include all information contained within Standard 5.2 of the National Minimum Standards for Younger People. (Previous timescale of 1/9/04 is partly met). DS0000004861.V276498.R01.S.doc Version 5.1 Page 24 18 Clive Street 4. YA6 15 To review and expand the care planning system by: 1) To ensure that all aspects of care are included. For example, health care and nutrition. (Previous timescale of 1/9/04 is partly met). 2) To ensure guidelines are established with regard to the administration of any P.R.N. (as and when required) medication. (Previous timescale of 1/9/04 is not met). 3) To demonstrate that families, friends and advocates are involved in the drawing up and reviewing of care plans. (Previous timescale of 1/9/04 is not met). 4) To demonstrate that service users are involved in the drawing up of their care plans through a person centred planning process. (Previous timescale of 1/9/04 is not met). 5) To re-produce care plans in a format suitable for service users. (Previous timescale of 1/9/04 is not met). 01/06/06 5. YA9 13(4)(c) 6) To ensure that all care plans are reviewed with the service user (involving significant professionals) at the request of the service user or at least six monthly and updated to reflect changing needs. The home must ensure that all 01/05/06 aspects of risk taking are included in the service users risk assessment. These must be reviewed on a regular basis. (Previous timescale of 8/9/03 is DS0000004861.V276498.R01.S.doc Version 5.1 Page 25 18 Clive Street partly met). To expand risk assessments to ensure that the level of risk is clearly identified (high, medium or low). (Previous timescale of 1/10/05 is not met). To discuss with service users the option of holding a key to the front door and to record outcomes in individual care plans. If keys are with held for any reason a risk assessment must be undertaken. (Previous timescale of 1/9/04 is not met). To obtain and introduce a nutritional screening and assessment tool. (Previous timescale of 1/7/05 is partly met). Service users personal preferences must be recorded in their care plans. For example bath times, personal care assistance provided by opposite gender staff. (Previous timescale of 18/2/04 is not met). To introduce a formalised procedure for the monitoring/screening of service users health with regard to potential complications such as testicular, breast and cervical cancer. (Previous timescale of 1/9/04 is not met). To ensure that all service users receive regular ophthalmic checks. (Previous timescale of 1/7/05 is partly met). To improve the control and administration of medication practice by: 1) Accredited training for staff in the safe handling of medication must include the elements identified in Standard 20.10 and 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 26 6. YA16 17(1)(a) 01/06/06 7. YA17 12(1)(a) 01/06/06 8. YA18 12 01/10/05 9. YA19 12(1)(a) 01/10/05 10. YA20 13(2) 01/06/06 be appropriately recorded on their individual training records. (Previous timescale of 4/11/03 is not met). 2) To review and expand the medication policy to include all subjects: disposal, drug errors, storage, key holding etc. (Previous timescale of 1/5/05 is not met). 3) To establish a household remedy policy for the use of over the counter medicines which must be ratified by the G.P. To ensure that the administration of any household remedy is fully recorded on a medication administration record (MAR) sheet. (Previous timescale of 1/5/05 is not met). 4) To ensure that care plans contain an up to date medication profile. (Previous timescale of 1/5/05 is not met). 5) To ensure that where there are any changes or discontinuation to medication either the G.P. signs the MAR sheet, or if this is not possible then two staff signatures are obtained with reference to the copy of the new prescription. (Previous timescale of 1/5/05 is not met). 6) To ensure that records relating to the receipt of medication are more detailed. For example to record the quantity and strength of medication received. (Previous timescale of 1/11/05 is not met). 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 27 7) To ensure that consent is obtained to medication from each service user and recorded in the care plan (or to acknowledge if this is not possible). (Previous timescale of 1/11/05 is not met). 8) To ensure that all drugs administered are fully recorded on the MAR sheet. (Previous timescale of 1/11/05 is not met). 9) To ensure that all creams/ointments are labelled with the date of opening. 11. YA23 13(6) All information about financial matters, kept by the home on the service users behalf, must be kept available with their individual records, for example details of appointees, how service users manage their own finances. (To devise individual care plans). (Previous timescale of 8/9/03 is not met). All staff must receive training in adult protection issues. (Previous timescale of 21/1/04 is partly met). To review and update the adult protection policy to include details of the Protection of Vulnerable Adult (POVA) procedures. (Previous timescale of 1/7/05 is partly met). To obtain an up to date copy of the Local Authority vulnerable adult abuse procedures. To ensure records are kept of financial transactions made on behalf of one service user who 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 28 01/06/06 12. YA24 23(2)(b) requires more support to manage their personal allowance.. To provide a second hand rail on the stairs. To pursue plans to replace worn mattress in ‘A’’s bedroom. 01/05/06 13 14. YA30 YA35 13(3) 18(1)(c) To obtain and use liquid soap in the kitchen/laundry area. To provide a staff training and development plan which includes mandatory and specialist training. (Previous timescale of 1/9/04 is not met). To establish individual staff training and development assessment profiles. (Previous timescale of 1/9/04 is not met). 01/05/06 01/06/06 15. YA33 17(2) 16. YA36 18(2)(a) To provide staff with equal opportunities and disability equality training. (Previous timescale of 1/9/04 is not met). To ensure that the duty rota is 01/05/06 kept accurate and up to date and identifies the night time sleeping in shift. A planned programme of 01/06/06 supervision and annual appraisal must be implemented. (Previous timescale of 4/11/03 is not met). Quality assurance and 01/06/06 monitoring systems must be developed by the home to measure its success in achieving its aims, objectives and statement of purpose. (Previous timescale of 21/1/04 is not met). The home must obtain and keep available all information on staff as detailed in Schedule 2 of the Care Home Regulations 2001. (For example proofs of DS0000004861.V276498.R01.S.doc 17. YA39 24 18. YA41 17(2) 37 01/06/06 18 Clive Street Version 5.1 Page 29 identification). (Previous timescale of 1/9/04 is partly met). To ensure that all records containing sensitive information are held securely as in compliance with the Data Protection Act 1998). (Previous timescale of 1/9/05 is not met). 19. YA42 18(1)(c) To provide up to date training for 01/06/06 all staff in: 1) infection control. (Previous timescale of 1/9/04 is not met). 2) health and safety. (Previous timescale of 1/9/04 is partly met). 3 first aid awareness. (Previous timescale of 1/9/04 is partly met). 4) food hygiene. (Previous timescale of 1/9/04 is partly met). 5) moving and handling. (Previous timescale of 1/9/04 is partly met). 20. YA42 23(4)(a) To undertake a fire safety risk assessment as in compliance with the Fire Safety (Work Place) Regulations 1999. (Previous timescale of 1/7/04 is not met). To carry out individual risk assessment on all products used which are hazardous to health as in compliance with the Control of Substances Hazardous to Health 1988. (Previous timescale of 1/9/04 is not met). 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 30 01/06/06 To ensure that there is regular testing and recording of all cooked food, fridge and freezer temperatures as in compliance with the Food Safety (Temperature Control) Regulations 1995. (Previous timescale of 1/5/05 is partly met). To seek advice from the West Midlands Fire Safety Officer with regard to the current fire safety practice and in particular the possible need for interlinking of the smoke alarm system. To undertake weekly testing of the smoke alarms. To reinstate regular (at least monthly) testing and of water temperatures from all outlets with appropriate records maintained. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 31 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 YA20 YA23 YA24 YA30 Good Practice Recommendations To consider obtaining a Controlled Drugs Register. To obtain a copy of the Department of Healths No Secrets guidance. To consider fitting a more suitable lock to the communal bathroom such as a pass lock. To install a paper towel dispenser in the kitchen area. To seek advice as to the feasibility of installing a small wash hand basin in the kitchen area. 5. YA37 To consider providing the manager with training in risk assessment and management. 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 18 Clive Street DS0000004861.V276498.R01.S.doc Version 5.1 Page 33 - 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. 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