Inspection on 05/08/05 for 23 Barncroft Street

This inspection was carried out on 5th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

23 Barncroft Street 27/05/09

23 Barncroft Street 19/06/07

23 Barncroft Street 06/07/06

23 Barncroft Street 16/12/05

23 Barncroft Street 09/02/05

23 Barncroft Street 14/10/04

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 23 Barncroft Street Hill Top West Bromwich West Midlands B70 0QJ Lead Inspector Debbie Sharman Unannounced 5 August 2005 th 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. 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 3 SERVICE INFORMATION Name of service 23 Barncroft Street Address Hill Top, West Bromwich, West Midlands, B70 0QJ 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 556 8809 0121 556 8809 Milbury Care Services Limited Ms Diana Reid Care Home 4 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (2) of places 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 One service user in the category LD may also be DE and will remain until such time that the current service users placement is terminated. Date of last inspection 9th February 2005 Brief Description of the Service: 23 Barncroft Street is an adapted bungalow property, which is owned and managed by the Milbury organisation. The home is situated in the Hilltop area of West Bromwich, which is easily accessible and is close to nearby public transport routes. Local shops and amenities are also available. The accommodation consists of four single occupancy bedrooms, kitchen, lounge/dining area, and bathroom and toilet facilities. The home offers a small enclosed rear garden/patio and off road parking to the front of the property. A range of services are on offer and include social and recreational pursuits, an open visiting policy, access to visiting healthcare professionals, a varied menu, and in house activities such as aromatherapy, sensory sessions, and games. Service users are offered 24-hour personal care and support, including two wakeful night staff on duty. All staff aim to enable service users to live an ordinary life in the community. 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector conducted this unannounced inspection, which began at 9.30am. The manager was not available and therefore the senior staff member on duty supported the inspection. Service users are non verbal and therefore could not be interviewed. The Inspector observed their demeanour and responses to staff and the general indication was that they were settled and content. The Inspector toured the environment, observed the administration of medication and assessed documentation. Ten national minimum standards were assessed, as was progress towards previously required improvements. Not all areas could be assessed as, to do so fully, required the manager’s contribution. What the service does well: What has improved since the last inspection? What they could do better: A variety of improvements are required to the environment to provide a more pleasant and safe living environment for service users. Décor is scruffy in the hall, lounge, bathroom and toilet. The bathroom door lock did not work providing no assurance of privacy for service users. Windows throughout the 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 6 premises were very dirty. Fire doors were wedged open, which compromises fire safety, and a notice with a broken glass frame remained on display in a public area of the home. Outside garden debris covered most of a pathway and the garden fence was both leaning and broken, rendering the garden unfit and unsafe for residents to use. Infection control procedures including food storage temperature control and pet care must improve for the health and safety of service users. The freezer also needed to be defrosted and its drawers were all broken. The home’s adult protection procedure must be reviewed as it is potentially misleading and discussion with staff showed that in the event of any adult protection incident, they are likely not to know how to correctly proceed. Medication was not signed for on some occasions and there is evidence that the home has been slow to implement the advice of the supporting pharmacist. 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. 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 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 standard(s) Not assessed during this inspection EVIDENCE: 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 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 standard(s) EVIDENCE: These Standards were not assessed at this inspection 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 10 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, 17. Service users are not proactively supported to maintain family links and friendships. Varied meals are provided in a manner that meets individual needs. EVIDENCE: Care plans do not address the arrangements for family contact. None of the service users have a lot of family contact but omissions in care planning do not explore family’s needs, wishes or restrictions. The home does not proactively seek to promote contact with families. For example a staff member spoken to had not considered the possibility of contacting families regularly to generally update them and to keep in touch on behalf of the service users who are non vocal. The staff member responded to this idea positively seeing the advantages over only contacting families when there is a problem. Arrangements for contact with family must be reviewed for each service user, any agreements recorded in the care plan and contact clearly evidenced to facilitate easy monitoring of the plan’s effectiveness. Menus and food intake records are available. One service user has an individualised menu to account for the need to puree his food. None of the 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 11 service users are diabetic or need an adjusted menu for religious reasons. Swallowing assessments are in place and whilst there are not nutritional risk assessments in place a dietician is providing support for two service users. Weights are not consistently monitored with weights for two service users not having been taken for four months at the time of inspection. Weight records for a further service user were not available at all. Service users are non vocal but the senior staff member who is responsible for the menu was able to recount how service users would indicate their dislike of a product or meal. All service users require staff support to eat. The Inspector was told that service users are not taken to the table to eat routinely as it is more comfortable for them to eat in their own chairs. The advice of an occupational therapist must be sought about this to see how service users could be supported to safely and comfortably eat at the table. It was pleasing to see that a mid morning snack is provided for service users in recognition of the length of time between breakfast and lunch. Drinks are also provided regularly. 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 12 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) 20 In general, medication was seen to be administered safely by the home. EVIDENCE: The Medication policy is comprehensive, including guidelines about administration, storage, errors, homely remedies, ordering, consent and covert medication. The Inspector observed medication being administered and practice was considered to be good. Of particular note was the staff member’s respectful and consultative approach to the service users whilst supporting them to take their medication. Gaps were present within the Medication Administration records. The manager must commence a medication audit system ensuring that staff take responsibility for bringing gaps to the attention of the manager or senior on duty for investigation without delay to ensure that action is taken as soon as possible to maintain the health treatment for the service user. Investigations must be recorded and any errors in medication notified to the Commission for Social Care Inspection. A previous requirement for improvement in respect of ‘As required’ medication has not been acted upon and improvement not achieved. 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 13 The home has support from a visiting pharmacist. The inspector noted that the pharmacist has twice had to repeat recommendations for improvement. The manager must ensure that the pharmacist’ advice is implemented without delay. 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 14 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, 23. A complaints procedure is in place but needs to be in a format which can be understood by service users. Systems are in place which, in general, protect service users from abuse. EVIDENCE: The complaints procedure is extensive and contains guidance about timescales for the resolution of complaints. It also includes the contact details for the Commission for Social Care Inspection. This procedure is publicly available in the entrance to the home but is not in a user-friendly format. The complaints procedure must be accessible and easy to understand for all stakeholders / service user representatives. The senior staff member was not aware of any complaints having been made about the service provided. No complaints have been brought to the attention of the Commission for Social Care Inspection. Procedures are in place for responding to suspicion or evidence of abuse, although the procedures have not been updated to include new Protection of Vulnerable Adults (POVA) processes. Examination of the policy also shows that a flow chart updated in March 2005 outlining steps to take in the event of an incident advises staff to seek the victim’s permission to report the incident to Social Services. This is good practice but the guidance must make it explicitly clear what is expected of staff and managers in the event of permission being refused. A scenario given to a staff member showed that the staff member has not been suitably supported to fully know what action to take and not take in the event of witnessing an adult protection incident. A Physical intervention policy is also in place as is guidance on accepting gifts / benefiting from service user wills etc. A whistle blowing policy was not available for inspection and is therefore not considered available to guide staff. The Inspector was informed that service users do not present behaviours that challenge although one 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 15 service user will inflict self-injury. The senior staff member spoken to demonstrated appropriate ways of responding to this risk. Service user monies were checked and are appropriately managed. But the previous requirement to ensure two signatories remains partly met. There have been no allegations of abuse and no staff referred to the Protection of Vulnerable Adults list. 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 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 standard(s) 24, 30 Aspects of maintenance requirement improvement to promote both the safety and homely ambiance of the premises. The home is well equipped to meet the needs of service users. Systems are not in place to adequately control the risk of the spread of infection. EVIDENCE: Communal areas of the premises require decoration. For example the paintwork and carpet in the entrance hall is scruffy and wallpaper is peeling from the lounge ceiling and toilet room. The skirting in the lounge and areas below the dado rail are particularly in need of redecoration. In the kitchen the freezer needed defrosting, its drawers were broken and the lock on the bathroom door was reported as having been broken for a long time. An external fence at the rear of the property was leaning sharply and one bar of the fence had broken. Windows through out the property were very dirty. The property is however discreet within the community. There is an assisted bath, grab rails, a hoist to meet service users needs and a separate disabled access shower. Furnishing is of a good quality. Bedrooms are well equipped 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 17 and personalised with adapted chairs and beds that raise and lower. One bedroom is furnished with sensory equipment. All bedrooms have a lockable facility, restricted windows, appropriate door locks and storage. The Inspector asked the staff to remove a framed organisational statement from the entrance hall foyer that was posing a risk to staff, service users and visitors. The glass in the frame was badly cracked. The home’s fire risk assessment indicates that ramps are required to help service users to exit the building safely in the event of fire. These have not been provided but are, the Inspector was told, planned. The Fire Officer visited the home in July 2004 and the subsequent report arising from the visit is satisfactory. The home has its own minibus to support service users access to the community. The premises smell fresh throughout but practices to reduce the risk of infection through cross contamination are not sufficiently robust. Paper towels, liquid soap in preference to bars of soap were not consistently available at all appropriate sites throughout the building. There is evidence of the risk of cross contamination within the laundry and during the transportation of soiled linen through the building to the laundry. Fridge and freezer temperatures were also consistently incorrect. It was unclear whether the incorrect temperatures were as a result of the temperatures being incorrect or being recorded incorrectly. Discussion with staff highlighted the need for staff to be supported to understand correct temperature ranges and reading. The cold storage temperatures are also only being taken once per day instead of twice. The home’s Infection Control Policy is comprehensive and includes detailed relevant advice about infection risks from pets. The policy states that inoculations are required for pets living at the home. Staff advised the Inspector that the pet dog had not to their knowledge been vaccinated in 2.5 years. Annual vaccinations are required. 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 36 Recruitment practice is robust and ensures the protection of service users. Staff are supported and the provision of supervision to staff is ongoing. EVIDENCE: The Inspector assessed the personal file of a recently recruited staff member. All appropriate checks had been carried out prior to the staff member’s appointment. Sufficient identification for the staff member was also on file. Omissions identified were a photograph and job description. However outcomes for service users are considered to be good in general. Progress is being made with the supervision programme for staff. The Inspector assessed supervision provided to a senior staff member. Four supervisions have been provided in the previous 13 months, which is 2 short of the minimum standard. However the current manager has provided 3 of those supervisions within the previous 8 months. Six must have been provided to all staff by the end of 2005. The staff member whose records were assessed had last had an appraisal in January 2003. Appraisals must be provided annually. The staff member’s competency in administering medication had also been assessed recently by the manager, which is good practice. A staff member spoken to said she feels well supported by the manager. 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 19 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) 42 Service users generally live in a safe environment. Addressing the omissions identified will further reduce risk and enhance safety. EVIDENCE: Equipment is in place to support the safe moving and handling of service users. Fire systems are appropriately serviced and regularly checked in-house. Fire drills have been carried out twice since March 2005 complying with a previous requirement. The fire risk assessment has been reviewed recently (May 05) and has concluded that ramps are required to support the safe egress of service users who are dependent on others to mobilise. Fire training however is not sufficiently provided which does not support staff or service user safety in the event of a fire. A five year total electric installation test certificate was not available and the Inspector could not be reassured that this had been carried out to protect service users from the risk of electrical accident and or electrical fire. Water temperatures are being taken and recorded but, as with the cold food storage temperatures, without action in the event of temperatures which fall 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 20 outside of safe limits. Some water temperatures were recorded at 46 degrees, 3 above the higher limit risking accident through scolding. Staff need to be appraised of the acceptable ranges and action they must take in the event of non compliance. A water risk assessment has been commissioned which concluded that the water tank is very dirty and needs cleaning and chlorinating. No evidence was produced to demonstrate that this has been carried out. All other maintenance checks and services were appropriately maintained. 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 21 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 x x x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 1 Standard No 11 12 13 14 15 16 17 x x x x 1 x 2 Standard No 31 32 33 34 35 36 Score x x x 3 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 23 Barncroft Street Score x x 2 x E55 S4840 Stg4.doc Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x 23 Barncroft St V245656 050805 Version 1.40 Page 22 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 5 Requirement To produce the Service User guide and other information about the home in a range of formats suitable for the people for whom the home is intended (e.g. appropriate language or pictures, audio / video) Requirement first made Feb 05 and not met since May 05 To demonstrate ways in which service users are involved in the day to day running of the home and provide evidence of consultation / opportunities for decision making with service users based on outcomes for individuals To further demonstrate how routines within the home are flexible and service users are enabled to exercise control. To ensure all risk assessments are reviewed / updated, including personal risk management strategies for individuals, plus equipment such as cot sides and the use of the hydraulic / assisted bath. The Acting Manager is advised to review the day activities for service users and explore the 23 Barncroft St V245656 050805 Timescale for action NOT MET 31.12.05 2. Ya7 12 Not Assessed 31.10.05 3. YA9 12, 13 Not Assessed 31.10.05 4. Ya12 12, 16 Not Assessed 31.10.05 Page 23 23 Barncroft Street E55 S4840 Stg4.doc Version 1.40 5. YA15 12, 15 option available in terms of external support / provision 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. Arrangements for contact with 31.12.05 family must be reviewed for each service user, any agreements recorded in the care plan and contact clearly evidenced to facilitate easy monitoring of the plan’s effectiveness. New Requirements at August 2005 Nutritional risk assessments must be undertaken for each service user and any risks must be included in a plan of care which must be carried out, reviewed and evidenced. All service users must be regularly weighed, the results must be recorded and records must be available for inspection and to inform the risk assessment and plan of care. The advice of an occupational therapist must be sought about this to explore how service users can be supported to safely and comfortably eat at the table New Requirements at August 2005 To ensure that specialist services (e.g. dietician) are consulted with a view to risk assessing and implementing any dietary constraints or weight reducing measures. To ensure all unexplained gaps 6. YA17 Sch 3 (3)(m) 13(4) 13 31.9.05 31.8.05 31.10.05 7. YA19 12 PART MET (not evidenced) 30.9.05 NOT MET Page 24 8. Ya20 13 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 9. YA20 13 in recording on medication administration records are accounted for and staff are advised of the need to complete the MAR sheet appropriately. Protocols for the administration of PRN (when required) medicines must include the maximum prescribed dosage in any 24 hour period. Certificated evidence of staff training in the safe handling of medication must be available for inspection on the premises. The manager must regularly audit the medication records with written outcomes and must also ensure that staff take responsibility for bringing gaps to the attention of the manager or senior on duty for investigation without delay New Requirement at August 2005 The manager must ensure that the support pharmacist’s advice is implemented without delay. New Requirement at August 2005 The complaints procedure must be accessible and easy to understand for all stakeholders / service user representatives. 5.8.05 NOT MET 31.8.05 NOT MET 30.9.05 30.9.05 10. YA20 13 11. YA20 13 31.8.05 12. YA22 22 31.10.05 13. YA23 13 New Requirement at August 2005 NOT MET Certificated evidence of staff training in adult protection issues 30.9.05 must be available for inspection on the premises. The home’s adult protection policy must contain reference to the Protection of Vulnerable Adults list and its relevance A second witness signatory NOT MET 31.10.05 PART MET Version 1.40 Page 25 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 14. Ya23 13(6) should be obtained at the time on all financial transactions involving service users money. The home’s Adult protection procedures must make it explicitly clear what is expected of staff and managers in the event of service users permission to report incidents / allegations of abuse being refused. New Requirement at August 2005 A Whistle Blowing policy must be made available within the home. New Requirement at August 2005 The rear of the property and far corner of the garden area needs to be cleared of debris and made safe The manager must ensure that a maintenance programme is developed to include a plan with targets dates to address the following: · Redecoration of communal rooms as a priority. · Regular defrosting of the freezer · Replacement of the freezer or freezer drawers · Repair of the lock to the bathroom door. · Repair / replacement of the broken fence to the rear / side of the property. · A regular programme of window cleaning. · The provision of ramps to exit the premises in the event of fire as per fire risk assessment. A copy must be supplied to the Commission for Social care Inspection by the date set. New Requirement at August – No progress 30.9.05 31.10.05 15. YA 23 13(6) 30.9.05 16. YA24 23 NOT MET 31.8.05 30.9.05 17. YA24 23 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 26 2005 18. YA30 13(3) The manager must take steps to improve infection control practice. New Requirement at August 2005 To ensure that vacant carers posts are recruited to and all shortfalls in staffing provision are addressed. A minimum of three staff, including a senior carer must be on duty between 7.45am– 10pm (This must be in addition to the Managers 20 hours per week supernumerary time) Rotas should make clear the designation of each member of staff and contracted hours of employment. (Met with the exception of the manager role etc) The number of senior care staff should be reviewed to offer increased support to the service The rota and shift pattern needs to be reviewed to ensure compliance with the issues noted above. 30.9.05 19. YA33 YA34 18 Not Assessed 31.8.05 Not Met – resident numbers reduced by one 20. YA33 18 PART MET 31.8.05 NOT METSeniors decreased in number 21. YA39 24 Requirements first made February 2005 and not met since 31.3.05 The acting manager should Not consider ways in which service Assessed users and their relatives / 31.10.05 representatives can be part of the quality assurance system, and ways of sharing the outcomes of the process with relevant persons and stakeholders in the home. Requirement first made February 2005 and due to be met by 31.8.05 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 27 22. YA41 YA18 YA16 17 23. YA42 23 The content of ‘daily notes’ should be reviewed to ensure full and detailed records of all care and services provided are maintained. Requirement first made February 2005 and due to be met by 31.5.05 Fire Safety – All staff must be provided with fire safety training. Not Assessed 31.8.05 Not Met – see immediate requirement issued. Part Met – risk assessment in place but not been implemented. 31.10.05 Immediate The regulation of water temperatures and design solutions, to control the risk of legionnella must be in place – water chlorination / bacteriology / legionella. (A risk assessment certificate should be available 24. YA42 23(4)(d) All staff must receive fire safety training twice in every 12-month period. Fire training for those staff that have not received fire training (K.L., M.R. E.W., D.R.) must be booked by 12 August 2005 with the training date and staff names confirmed in writing to the Commission for Social Care Inspection by this same date at 4.30p.m. A detailed training action plan to ensure that all staff receive timely fire training (twice in every 12 month period) must be submitted to the Commission for Social Care Inspection by 12 August 2005 at 4.30 p.m. New Requirement at August 2005 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 28 25. YA42 23 13(4) A five-year total electric installation test must be provided to the Commission for Social Care Inspection by the date given. New Requirement at August 2005 Water outlet temperatures must all comply with the recommended safe range. Action must be taken without delay when water temperatures do not comply with the safe range. Cold storage temperatures must be taken and recorded accurately twice per day and action must be taken when temperature does not comply with the safe and legal range. New Requirement at August 2005 The water tank must be cleaned and chlorinated as per the recommended outcome of the water risk assessment. New Requirement at August 2005 31.10.05 26. YA42 13(4) 13(3) 5.8.05 27. YA42 13(4) 23 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. No. 1. 2. Refer to Standard YA18 YA32 Good Practice Recommendations In the interests of service users dignity, it is recommended that the stock of incontinence aids are stored discreetly in the bathroom rather than on display. 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. E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 29 23 Barncroft Street Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen B62 8BR 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 23 Barncroft Street E55 S4840 Stg4.doc 23 Barncroft St V245656 050805 Version 1.40 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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