Inspection on 17/08/05 for 34-36 Langstone Road

This inspection was carried out on 17th 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

34-36 Langstone Road 22/02/08

34-36 Langstone Road 11/09/07

34-36 Langstone Road 14/11/06

34-36 Langstone Road 22/02/06

34-36 Langstone Road 17/02/05

34-36 Langstone Road 03/09/04

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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 Langstone Road - 34/36 Russells Hall Estate Dudley West Midlands DY1 2NJ Lead Inspector Jayne Fisher Announced 17 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. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Langstone Road - 34/36 Address 34/36 Langstone Road Russells Hall Estate Dudley West Midlands DY1 2NJ 01384 234510 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) Langstone Society Mrs Patricia Joan Brookes Care Home 8 Category(ies) of LD - Learning Disability (7) registration, with number LD (E) - Learning Disability over the age of 65 of places (1) Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17th February 2005 Brief Description of the Service: Langstone Road is a residential care home registered for eight people with a learning disability. Originally two semi-detached properties It maintains a similar appearance to other residential properties in the area and is situated close to local shops and public transport links. The Registered Provider is Langstone Society which is a Registered Charity who rent the premises from the Churches Housing Association of Dudley District Limited (CHADD) . Facilities include 6 single and 1 double bedroom, kitchen, dining room, 2 sitting rooms, and sufficient numbers of bathrooms and toilets. Car parking is available at the front of the property with gardens at the rear. The homes aim is to provide a homely and stimulating environment, ensuring that each person exercises maximum choice and control over their own life and maintains independence. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 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 7.15 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: formal and informal interviews with the manager, 3 support staff who were on duty and the Chief Executive of Langstone Society who visited for part of the inspection process. There was also a tour of the premises. Langstone Road provides care for eight younger adults who have a range of learning disabilities, who may exhibit challenging behaviour, who have communication needs and associated health care problems. Three residents were away on holiday at the time of the inspection. However there was an opportunity to meet the remaining five residents who were at home during varying stages of the inspection process. It was not possible to have an open dialogue with all residents therefore the inspector used a variety of communication methods including brief chats and discussions, observation of body language and gestures, plus observed interactions between residents and staff. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of visits undertaken by the owner’s representative, the pre-inspection questionnaire, and an action plan submitted by the home following the last inspection. Feedback questionnaires were received from five relatives and one General Practitioner. What the service does well: There was a relaxed atmosphere through out the inspection visit. Residents responded warmly to staff with lots of smiles and playful banter. Three residents were not at their day centre and spent the day sitting out in the sunshine or inside the house in their own bedroom or communal lounge. Two residents returned from their day centre and later in the evening some residents chose to attend a local social club. Residents were well groomed and dressed in modern clothing which reflected their personalities. Residents wandered into the manager’s office at their leisure and listened or joined in the inspection process. There is no restriction upon freedom of movement within the home which residents clearly regard as their own environment. Residents chatted about their favourite hobbies and outings. There is a strong commitment from staff to ensuring that residents retain their family links. There were lots of positive comments made by relatives which included: “The home is excellent. I am always made to feel very welcome”. “It is very comfortable for the residents and there are caring staff”. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 6 The furniture and furnishings are homely and promote a family type environment. Residents are included in choosing colour schemes for furnishings. All parts of the home were very clean and tidy. The majority of residents attend day centres and/or local college placements and undertake a variety of activities which promote personal development. Residents are able to have an annual holiday and can choose various locations. They are also able to go away for a short break if they wish. There is a stable and well trained staff group who demonstrate a commitment to the residents and in providing a good quality service. What has improved since the last inspection? What they could do better: Although residents enjoy community based outings these have been restricted at times due to staffing shortages. A range of activities are provided in-house but there needs to be improved planning and recording systems. Further information is needed in contracts/terms and conditions of occupancy so that service users and staff are fully aware of what is included as part of the basic contract fee. Residents enjoy a healthy diet but more effort is needed by staff in supporting them to make choices from the daily menu, providing more options and encouragement in menu planning. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 7 Recruitment and selection procedures of new staff require improvement in order to offer residents greater protection from abuse. Policies and procedures relating to vulnerable adult abuse and record keeping also needs improvement. Induction programmes for new staff still need to be introduced that provides them with the skills and knowledge to provide care for persons with a learning disability. 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. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5 The Statement of Purpose and Service User Guide are very good providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to be made. Service users would benefit from updated contracts/terms and conditions of occupancy whereby they could have accurate information regarding what is included as part of their basic contract fee. EVIDENCE: Since the last inspection the statement of purpose has been reviewed and updated. The service user guide now contains service users’ views as requested. Both documents are well organised and easy to read with comprehensive information available also in pictorial format. A system of Licence Agreements between the landlords: Churches Housing Association of Dudley District Limited (CHADD) and the individual service user is in place. This document is included in service user plans and a copy is contained within the service user guide. These need to be updated as they were last issued in 2002 and therefore do not contain up to date fee levels. In addition the documentation needs review to comply with all of the requirements of the National Minimum Standards (NMS) 5.2. For example to include details of the specific room number occupied, additional charges and arrangements for review of the care plan. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 10 There is a central activity fund. The manager could not confirm whether this During fund was part of the basic contract fee for each service user. interviews staff also had confusing ideas as to what this fund was used for and how this was disseminated to service users. Further clarification is required from the Local Authority Commissioning Department as to what the current basic fee includes in respect of activities and confirmation from the service provider as to how the central activity fund should be distributed to residents in order to promote equality. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8 Service users are consulted on some aspects of life within the home, however more opportunities need to be offered in order for them to be able to influence key decisions regarding the home and service they receive. EVIDENCE: The manager states that residents are offered opportunities to participate in the recruitment and selection of staff. Examples were given of how a resident had participated recently in this process. It is recommended that written procedures be established and consideration of offering training and support to residents which would further enhance their involvement. There are monthly service user meetings held which are fully recorded. Residents discuss their preferences for activities and outings. It was pleasing to see that they had also recently been consulted regarding the colour of the new carpet in the hallway and stairs. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 12 Service users should also be offered opportunities to contribute to policies and procedures and representation in management structures. Service user questionnaires are completed (see further comment in standard 39), however these were last completed over two years ago according to the manager and should ideally be carried out more frequently. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 and 17 Residents take part in appropriate daily activities in order to encourage personal development however, social inclusion has been restricted due to staffing shortages, and as a result service users are not always able to enjoy social stimulation and follow their own hobbies and interests. Staff support service users to maintain family links thereby enriching their lives. The home promotes healthy eating although service users would benefit from more assistance in choice making from the menu plan. EVIDENCE: Residents have opportunities for personal development. For example one resident was seen (without prompting by staff) to clear away after a lunch time meal. Staff described how they encourage residents to participate in daily living tasks. All residents (with one exception) attend day centres and college placements. Care plans contain weekly activity sheets describing the type of placements they are attending. One resident commented “I like to go to the day centre”. Activities at day centres and colleges include pottery courses, arts and crafts, swimming and computers. One resident has completed a food hygiene course. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 14 Changes have recently been made to recording systems with regard to leisure and social activities provided in-house in the evenings and weekends. This is an attempt to identify more stimulating activities which is commendable. However it was not clear from recording methods whether activities were actually taking place. For example, during a ten day period one resident’s inhouse leisure and social activities consisted of mainly relaxing and watching television. The manager stated that more activities would have been undertaken but that staff had not recorded them. Whilst residents are offered outings, during interviews some staff felt that more community based activities could be offered. The manager acknowledged that these had become restricted of late due to staffing shortages (see further comment in standard 33). One resident stated that they enjoyed going to the cinema but could not remember when they last went. Minute from residents’ meetings in July and June contained requests from different residents to visit the cinema but this had not been arranged. During a 14 day period one residents’ community outings had consisted of a walk, a visit to Stourport and a ride in the countryside. The manager stated that on occasions certain residents would be offered outings but would refuse, however this needs to be fully recorded. As already mentioned there is a central activity fund but it is not clear from discussion with staff and management as to what basis this is allocated to different residents or who funds the budget (the Local Authority or service provider). This needs clarification in order to ensure that the fund is distributed appropriately. Through discussions with staff it is evident that residents are supported to maintain family links. Residents discussed how they enjoyed going to visit their relatives on a regular basis. All 5 relatives who completed questionnaires devised by the manager confirmed that they were made very welcome when they visited Langstone Road, and also confirmed that they could see their relative in private if they wished. Interviews with management and examination of the menu plan confirms that service users benefit from a healthy diet. Staff report that weekly menu plans are devised in consultation with residents however there are no records to confirm this other than on occasions, a service user’s initials have been written next to a meal to denote it was their choice. The menu only describes one choice for lunch and dinner. During interviews staff stated that they always asked residents if they would like an alternative to the meal described on the menu. However, records of residents’ food intake (which were not consistent), demonstrated that choices made did not deviate from the meal stated on the menu plan (except at breakfast). It was pleasing to see that on the evening, staff had not following the menu implicitly but had offered more than one filling for the jacket potato meal. At lunch time all Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 15 service users had received the same meal of a toasted bacon sandwich. There During interviews both the was no offer of condiments, pickles or salad. manager and staff felt that there were inconsistencies in the ways in which different staff supported residents to make choices and participate in menu planning. It is suggested therefore that written guidelines are introduced to encourage strategies such as pictorial menus or discussions of menus at service user meetings and to expand the written menu plan to include two alternatives for main meals. Any additional items discussed during this inspection are contained within the Requirements section of this report. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these standards were inspected. However, an evaluation did take place in respect of outstanding requirements. Good progress has been made in respect of the control and administration of medication practice although some items need further action. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a satisfactory complaints systems so that users’ views are listened to and acted upon. Policies, procedures and practice require improvement in order to offer service users more safeguards from abuse. EVIDENCE: The Statement of Purpose gives details regarding how to make a complaint. This includes information regarding the CSCI to whom complainants can make contact if they are unhappy with the Home’s investigation. There is also a pictorial complaints procedure which is included in the service user guide and in a booklet regarding choices. There have been no complaints received regarding the service during the last twelve months. Staff still require formal training in vulnerable adult abuse awareness. During interviews however, staff gave good accounts of how they would deal with any incidents of abuse. The current vulnerable adult abuse policy has been amended slightly as required at previous inspections to include details on No Secrets and the Protection of Vulnerable Adult (POVA) scheme. However, the policy remains basic and must include step by step procedures as to how staff should deal with abuse and also more information in respect of POVA. For example, there is no reference to the fact that a referral should be considered for any staff who are suspended and awaiting investigation. A copy of the POVA guidelines must also be obtained. (See further comment in standard 34 with regard to protection of vulnerable adults). The service provider acts as an appointee for the majority of service users in respect of managing finances. As requested a policy and procedure has been updated and this confirms that an annual audit is undertaken by an Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 18 independent auditor as required by recent guidance issued by CSCI in respect of corporate appointees. At a previous inspection the manager had also introduced a policy and procedure with regard to staff assisting service users to access their bank accounts though the use of cash point machines. This needs slight expansion for example, to make reference to the fact that monthly bank statements are checked alongside personal allowance records. In addition consideration must be given to further strategies to safeguard residents from financial abuse, such as a limitation on the amount of monies which can be withdrawn from a cash point machine (if necessary by the opening of a different account). Consideration should also be given with regard to reviewing cash point personal identification numbers (PIN) when staff leave employment. A written risk assessment must also be established to describe how individual service users are protected from financial abuse using the measures adopted by the home. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 Service users benefit from a clean and hygiene home with staff employing good infection control measures. EVIDENCE: A brief tour of the premises was undertaken. All communal bathrooms, lounges/dining areas, kitchen and laundry were visited. All areas seen were scrupulously clean. Since the last inspection improvements have been made in respect of infection control and clinical waste practice. For example clinical waste bins have been obtained and waste is collected on a regular basis by a professional contractor. There was a supple of personal protective clothing and paper towels available within the laundry area. Laundry procedures have been established but need further expansion in respect of good infection control practice such as the segregation of dirty and clean laundry. The laundry area itself not entirely suitable due to its limited size. For example there is nowhere to install a separate hand wash basin nor can clean and dirty clothing be easily stored. As service users’ needs change consideration must be given to extending the laundry area. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 and 35 There is a stable and well trained staff group who understand the complex needs of the service users. However, staffing shortages have impacted upon some aspects of care delivery. Recruitment and selection procedures need to offer more protection to service users. EVIDENCE: Seven out of the sixteen staff group are qualified to NVQ II or above. This is nearly 50 of the staff team which is requirement of the National Minimum standards. Specialist training is on-going. For example, staff have received training in autism. Further training has been identified with regard to nutrition. An update in epilepsy awareness would now be beneficial. During interviews staff competently described how they meet residents needs and respect their rights with regard to privacy and dignity which was confirmed during observation of practice. All five relatives who completed a satisfaction questionnaire confirmed that they were satisfied with the care provided by staff. A questionnaire completed by a General Practitioner confirmed that they felt staff demonstrated a clear understanding of residents’ needs. In general there is a very stable staff group. For example, one member of staff has worked at the home since 1988. Ten staff have worked at the home for longer than three years. However, recently there has been a slight turnover of staff, mainly sessional workers. There are currently a total of 90 Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 21 vacant hours. As a result of the loss of sessional staff there has been less flexibility in the duty rota and the manager has been covering shifts herself (as well as existing staff working over time). During a four week period the manager has been only above to cover four supernumerary shifts. There are no dedicated supernumerary hours and written proposals must be forwarded to CSCI has to how many hours per week will be allocated for this purpose. It was pleasing to see that there are regular staff meetings. The manager has also actively recruited two new male staff. A serious concern was identified with regard to poor recruitment and selection practice which does not promote the safety of residents. This necessitated an Immediate Requirement. A new member of staff commenced duties in May 2005 without a CRB disclosure or POVA check. The staff member had a CRB check from a previous employer, however, since 26 July 2004 CRB checks have no longer been portable. Whilst other pre-employment checks were in place this is not acceptable and contravenes a number of the Care Homes Regulations 2001. There still needs to be progress with regard to providing induction and foundation training for staff by an approved learning disability awards framework provider. This was discussed with the Chief Executive who states that problems have been incurred with identifying trainers, however this will now receive priority. In the interim staff will be undertaking an induction programme which is provided by the Training Organisation for Personal Social Services (TOPSS). Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41, and 42 The quality assurance system needs expanding so that users can be confident their views underpin service delivery and development. Record keeping needs improvement in order to safeguard residents. The health and safety of service users is given high priority by staff and management so that their welfare is protected. EVIDENCE: There are a number of different strategies for measuring quality and it was pleasing to see that the manager had devised questionnaires for relatives regarding service delivery. However, these strategies need to be combined into an overall quality assurance system culminating in an annual development plan which is based on a systematic cycle of reviewing and monitoring. This was discussed with the Chief Executive. Staff personnel files are still not held on the premises. These are still retained at the service provider’s head office which does not comply with the Care Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 23 Homes Regulations 17(2). As already identified in this report this practice is flawed and has the potential to place service users at risk. This was discussed with the Chief Executive. The majority of staff have undertaken statutory training. There is a central staff training programme however dates of training undertaken need to be inserted to make this a useful tool. The majority of maintenance and service checks were found to be up date. For example, there is regular checking of the fire alarm and emergency lighting system. All staff have received fire safety training and undertake monthly fire evacuation drills. Electrical items and fixed wiring have all been tested. There is good accident reporting. Examination of reports identified one service user who has sustained a few falls of recent and a written risk assessment is required as well as expansion of a risk assessment for assistance with the bath aid. It was pleasing to see that regular tests of water temperatures are undertaken. There is a Legionella risk assessment in place. This was undertaken in 2003 but there was no evidence to confirm that recommendations of works identified have been carried out which needs addressing. An environmental officer inspected food hygiene practice in December 2004. A couple of outstanding items still need attention as do requirements identified at previous inspections. On the whole food hygiene practice is good with the exception of a lack of consistency with regard to the testing of cooked food temperatures. It was noted that the home does not have a photo-copier or facsimile machine. The Chief Executive stated that this would receive action as in compliance with the Care Homes Regulations 2001. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 24 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 3 x x x 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x 2 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 2 2 3 x 2 Standard No 31 32 33 34 35 36 Score x 2 2 1 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Langstone Road - 34/36 Score x x x x Standard No 37 38 39 40 41 42 43 Score x x 2 x 1 2 x E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 25 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 5 Regulation 5(1)(b) Requirement To review the contract/licence agreement to include all information contained within Standard 5.2 of the National Minimum Standards for Younger People. (Previous timescale of 1/1/04 is not met). Timescale for action 1/12/05 2. 8 12(3) 3. 13 16(2)(m) To undertake a documented liaison with the Local Authority Commissioning Department to establish the exact nature of what the basic contract fee covers in terms of service users expenditure on activities and the nature of the central activity fund and how this is to be disseminated. To offer more opportunities for 1/12/05 service users to participate in the day to day running of the Home through joining staff meetings, representation in management structures, recruitment and selection of staff. (Previous timescale of 1/1/05 is partly met). To provide more opportunities 1/12/05 for service users to undertake community based activities on an individual and group basis Version 1.40 Page 26 Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc 4. 14 16(2)(n) based on their individual preferences and needs. Service users should be given the option to have a minimum seven-day annual holiday, outside of the home, as part of the basic contract price. (Previous timescale of 1/1/04 is not met). Service users should not be expected to pay towards staff expenses incurred whilst involved in activities, day trips, outings, holidays etc. (Previous timescale of 1/1/04 is not met). To improve recording systems for daily and/or weekly activitiy planning and evaluation. All refusals to participate in activities such as community outings must be clearly recorded. To ensure more consistent recording of service users chosen options from the daily menu. To review and expand the written menu plan. For example to ensure that there are at least two options available lunch and dinner. To establish written guidelines for staff with regard to menu planning and strategies for supporting service users in making choices. To make the following improvements to the control and administration of medication: 1) To review and expand the medication policy to include all areas of the control and administration of medication and 1/12/05 5. 17 16(2)(i) 12(1)(a) 1/11/05 6. 20 13(2) 1/11/05 Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 27 to follow good practice guidelines issued by the Royal Pharmaceutical Society. (To forward to CSCI). (Previous timescale of 1/1/05 is partly met). 2) To ensure drugs keys are either held by the sole person in charge or to identify a more secure location for the holding of keys. To carry out a written risk assessment if keys are not held by the person in charge. (Previous timescale of 1/1/05 is partly met). 3) To ensure that guidelines are established in individual care plans for the administration of P.R.N. medication. (Previous timescale of 1/1/05 is partly met). 4) To ensure that all household remedies administered are ratified by the General Practitioner including Aloe Vera and Almond and Lavender oil (any any other essential oils). (Previous timescale of 1/5/05 is not met). 5) To obtain copies of original prescriptions. (Previous timescale of 1/5/05 is partly met). 6) To ensure that computerized medication administration record (MAR) sheets contain correct information regarding the dosage of PRN treatment. (Previous timescale of 1/5/05 is not met). 7) To ensure that the household remedy policy stipulates the maximum dosage to be Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 28 administered within a stated timescale before the General Pracititoner must be consulted. 8) To liaise with the prescriber and pharmacist to ensure that computerized MAR sheets are suitably altered when changes are made. 9) To pursue plans to ensure that all staff receive training in the safe handling of medication from an accredited trainer. 1) To provide all staff with training in vulnerable adult abuse. (Previous timescale of 1/1/05 is not met). 2) To review and up date the vulnerable adult abuse policy. (Previous timescale of 1/1/05 is partly met). 3) To ensure that a written procedure is established with regard to service users’ financial contributions towards the use of a vehicle owned by one of the service users. To ensure that written consent is obtained with regard to the procedure and the use of this car. (Previous timesale of 1/1/05 is partly met). 4) To obtain a copy of the Department of Health guidance on the Protection of Vulnerable Adults Scheme (POVA). (Previous timescale of 1/5/05 is not met). 5) To ensure that the vulnerable adult abuse policy includes procedures relating to the POVA scheme. (Previous timescale of 1/5/05 is partly met). Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 29 7. 23 13(6) 1/12/05 6) To review and expand the written procedure with regard to assisting service users with the withdrawal of personal monies. 7) To carry out a written risk assessment for individual service users with regard to measures in place to prevent financial abuse. 8. 26 16(2)(c) Care plans need to identify where service users decisions and actions are limited. For example to conduct an audit of fittings and furniture provided, where service users choose not to have all facilities specified in Standard 26.2, (or if there is a health and safety risk)s, decisions must be entered onto their individual Service User Plan. (Previous timescale of 1/1/04 is partly met). To improve infection control practice by: 1) To provide a separate wash hand basin in the laundry area or to carry out a written risk assessment is this is not feasible. (Previous timescale of 1/6/05 is not met). 2) To establish and display written laundry procedures which follow good infection control practice. (Previous timescale of 1/6/05 is partly met). 3) To ensure that there is information displayed or available within the laundry regarding substances hazardous to health (COSHH). (Previous timescale of 1/6/05 is not met). Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 30 1/12/05 9. 30 13(3) 1/12/05 10. 32 18(1)(c) To provide all staff with training in epilespy awareness. 31/12/05 11. 33 18(1)(a) 12. 34 19(1)(b) 13(6) To progress plans to ensure that 50 of the care staff team are qualified to NVQ II or above by 2005. To ensure that the Manager is 1/11/05 allocated and carries out dedicated supernumerary hours and to forward written proposals to the Commission for Social Care Inspection. To ensure that all pre17/8/05 employment checks are undertaken prior to the appointment of staff including receipt of two written references and to obtain a photograph of the new employee as required by the Care Homes Regulations 2001. (Previous timescale of is not met - IMMEDIATE REQUIREMENT: 17 AUGUST 2005). To complete a written risk assessment identifying control measurs to safeguard service users from abuse whilst awaiting the return of a satisfactory criminal record bureau (CRB) disclosure check for R.B.). To forward to the CSCI by 19 August 2005 - IMMEDIATE REQUIREMENT. To complete a CRB application form for R.B. and send for processing. To forward a copy of the completed application form to the CSCI by 24 August 2005 IMMEDIATE REQUIREMENT. All staff must receive structured 1/12/05 induction (within six weeks) and foundation training (within six months) to Sector Skills Council specification and provided by a Version 1.40 Page 31 13. 35 18(1)(c) Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc LDAF (Learning Disability Award Framework) accredited trainer. (Previous timesale of 1/1/05 is not met). To ensure all staff complete training in equal opportunities and disability equality. (Previous timescale of 1/1/05 is not met). To develop an effective quality 1/12/05 assurance system to include feedback from service users, stakeholders in the community etc. (Previous timescale of 1/1/05 is partly met). To obtain and hold information 1/12/05 and documents on the premises in respect of persons carrying on, managing or working at a care home as listed in Schedule 2 and 4 of the Care homes Regulations 2001. (Previous timescale of 1/1/05 is not met). To ensure all staff have up to 1/12/05 date training in: 1) first aid awareness. (Previous timescale of 1/1/05 is partly met). 2) infection control. (Previous timescale of 1/1/05 is not met). 17. 42 13(4)(c) To undertake the following improvements with regard to fire safety and health and safety: 1) To ensure that the water system has undergone chlorination and a bacterial analysis. (Previous timescale of 1/6/05 is partly met). 2) To ensure that separate written risk assessments are undertaken for all substances used which are hazardous to Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 32 14. 39 24 15. 41 17(2) 16. 42 18(1)(c) 1/12/05 health (COSHH). (Previous timescale of 1/6/05 is not met). 3) To review and update the fire safety risk assessment. 4) To provide written evidence to the CSCI that all the recommendations/works identified in the Legionalla risk assessment of 2003 have been fully carried out. 5) To carry out a written risk assessment with regard to the service user who has been identified as prone to falls. 6) To expand the written risk assessment with regard to assisting one service user to use the bath seat. To make the following improvements to food hygiene practice: 1) To ensure consistent checking and recording of cooked food temperatures. (Previous timescale of 1/5/05 is not met). 2) To ensure all foods frozen by the home are labelled with the date of freezing. (Previous timescale of 1/5/05 is not met). 4) To ensure all dried foods such as cereals are stored in pest proof containers once opened. (Previous timescale of 1/5/05 is partly met). 5) To comply with all of the requirements identified by the environmental officer - food hygiene in report dated 1 February 2005. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 33 18. 42 13(4)(c) 1/11/05 19. 20. 43 16(2)(a)(ii To provide appropriate facilities for communication by facsimile ) transmission. 1/12/05 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. Refer to Standard 35 Good Practice Recommendations To update central staff training matrix with dates of training which has been completed. Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 34 Commission for Social Care Inspection Halesowen Office - 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 Langstone Road - 34/36 E55_S24966_Langstone Road 34_V235261_170805 Stg 4.doc Version 1.40 Page 35 - 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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