Inspection on 07/07/05 for 34 Pedmore Walk

This inspection was carried out on 7th July 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 Pedmore Walk 20/06/07

34 Pedmore Walk 15/06/06

34 Pedmore Walk 22/11/05

34 Pedmore Walk 15/02/05

34 Pedmore Walk 20/07/04

34 Pedmore Walk 20/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 34 Pedmore Walk Oldbury West Midlands B69 1BJ Lead Inspector Jayne Fisher Unannounced 7th July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 34 Pedmore Walk Address Oldbury, West Midlands, B69 1BJ 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 552 3645 0121 552 3645 Sandwell Community Caring Trust P. Whitehouse Care Home 8 Category(ies) of Learning disability (8), Physical disability (8), registration, with number Sensory impairment (8) of places 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15th February 2005 Brief Description of the Service: Pedmore Walk is a care home provision for 8 adults with severe learning disabilities who also have physical and sensory disabilities. The Home was originally a purpose built two storey children’s home situated in a residential area in Oldbury. The Home is approached via a pedestrian walk way adjacent to a school playing field. There is space for two vehicles in the secluded garden area at the rear of the property. A small block of shops is within easy walking distance and there is a good public transport system. The design and location of the Home blends in well with the local community. The Home has eight single bedrooms none of which are ensuite, located on the first floor and which are accessed by residents via a shaft lift. All service users attend differing forms of day care, which are either local authority or community-based resources. The Home provides a wide range of recreational and leisure activities and has the use of its own mini bus. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between the hours of 10.00 a.m. and 4.00 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: formal interviews with the manager and two members of staff who were on duty. There was also a tour of the premises which included visiting all communal areas, the kitchen, laundry, bathing facilities and service users’ bedrooms. Four residents were at home during varying stages of the inspection process. Open dialogue was not possible therefore the inspector relied upon body language and gestures, as well as observations of interactions between staff and residents. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of visits undertaken by senior management, notification of events sent to the Commission for Social Care Inspection and an action plan submitted by the home following the last inspection. The inspector was made to feel very welcome and would like to thank service users and staff for their assistance and co-operation during the visit. What the service does well: Staff demonstrate considerable knowledge regarding residents’ needs, likes and dislikes. They are caring, sensitive and patient in their approach and fully support residents to make their preferences known. As a result residents are treated with dignity and as individuals. All bedrooms are decorated in varying colours with matching bed linen that reflects residents’ personalities. Great care had been taken by staff in laying out personal clothing and towels ready for residents return from their day centres. Residents were dressed in modern and appropriate clothing. Interaction was very positive with lots of smiles and gestures to recognise staff presence. Staff are excellent in identifying any potential health care issues and ensuring that any problems are swiftly dealt with. There is close monitoring and staff work well with other health care professionals to ensure that the needs of residents are met. There is a comprehensive complaints policy and concerns raised are dealt with in an appropriate manner so that people can feel confident their views will be listened to. Staff have a good awareness of procedures to follow with regard to protecting service users from abuse. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 6 Staff feel well supported and can raise any issues with the manager. There is good communication and leadership and residents benefit from a well run home. What has improved since the last inspection? What they could do better: The building does not meet all of the needs of persons with physical disabilities. As a result residents are not able to achieve their maximum independence and in some cases their rights and dignity are compromised. For example, some bedrooms are too small to easily accommodate hoists and overhead tracking systems cannot be installed; corridors are too narrow to turn wheelchairs. This has been recognised by the service provider who apparently intends to build a new premises by 2007 however in the meantime the provider must maintain the décor and furniture at a good standard. Unfortunately there are a number of areas which require improvement in order to provide a more homely atmosphere. The care planning system requires improvement as it does not provide staff with easy accessible information nor does it identify aims or goals. A number of records required to ensure residents’ rights and best interests are safeguarded are not held on the premises thereby making an overall evaluation difficult. Induction and foundation training for new staff does not meet the required standards. Whilst the manager has made very good progress in addressing some of the issues identified at previous inspections, there are issues which are outstanding that require a response from the registered provider in order for the service to move forward. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.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 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.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 Prospective and existing service users have information they need to make choices about where to live although further information is necessary in order to allow for a more informed choice about the service. EVIDENCE: The Commission for Social Care Inspection is still awaiting an updated statement of purpose as requested at the last inspection. The document that was previously sent in 2004 does not include measurements of communal and individual bedroom spaces neither does it set out whether the physical standards of 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2 are met. It was very pleasing to see that staff have attempted to produce a service user guide in a format suitable for residents. As discussed this needs some further expansion to include physical details of the premises and information regarding staff. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 The system for care planning needs improvement as it does not provide all staff with easy access to information necessary in providing the care required by service users. Risk assessments are in place but not for all of the risks which are posed in delivery of care; an improved system would offer more protection to service users. EVIDENCE: As stated at previous inspections although case files contain a large amount of useful information, this represents an assessment of need and does not constitute a care plan. It is not possible to easily determine an individual’s current care regime. There are no aims or objectives, long term or short term goals identified. The manager agrees that the current system needs review but is awaiting approval from the provider. A member of staff who was interviewed struggled with finding the information requested from care plans and stated that she found the communication passport a more informative document regarding residents’ needs. There have been excellent attempts made by staff to introduce a person centred planning approach to care planning using life story books and essential life style planning. Staff have clearly worked hard to encourage families and other professionals to participate in this process. One service user now has a 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 11 essential life style plan in place which is creative and imaginative. Another service user is currently being assisted to establish their own essential life style plan. Good progress has been made with regard to advocacy. For example the manager has been successful in accessing a citizen advocate on behalf of one resident. Family generally act as advocates although ‘crisis’ and short term advocacy is available for all service users. All service users have either Local Authority or family members as appointees to assist in the management of their finances. Risk assessments are now being updated and reviewed regularly as previously required. The new simplified risk assessment format is an improvement. However, all aspects of activities and support needed by service users must be assessed in writing to ensure any risks are identified and control measures are adopted. For example there were no risk assessments in place for one resident who self harms, who uses a wheelchair and needs access to the passenger lift. Another resident’s risk assessment needed further information with regard to the exact number of staff involved in assisting with bathing. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 12 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) These standards were not assessed at this inspection. EVIDENCE: 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 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 standard(s) 18 and 19 Personal support is offered in such a way as to protect service users’ dignity and promote independence. The health needs of service users are well met. EVIDENCE: Staff provide sensitive and flexible personal support. For example a risk assessment was seen which gave detailed information regarding how a service user is supported to bathe. Residents’ preferences are observed with regard to getting up and going to bed times. For example one resident had chosen to have a lie in on the day of the inspection as they did not have to attend their day centre. As requested one residents’ care plan states their preference regarding cross gender personal care. This must be detailed in all residents’ care plans. Although there are plenty of technical aids and equipment to promote independence, more specialist equipment would be of benefit (see further comment in standard 27). The health needs of residents are of paramount importance to staff and their approach is commendable. For example, the manager has been persistent in trying to find a pressure relieving mattress to suit one service user’s needs. As a result pressure damage has been reduced. Another service user was referred to a specialist as staff were worried about the possibility of spontaneous fractures and as a result of their foresight the resident is now receiving treatment to reduce the risk of any future complications. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 14 Another resident’s skin condition is improved because of the intervention and suggestions made by the manager. Other service users were referred to the General Practitioner (G.P.) for tests for diabetes as staff had noticed an increase in fluid intake. Only slight improvements in respect of recording are necessary to supplement this excellent aspect of residents’ care. For example, as requested the manager has referred service users to the G.P. for audiology checks. This request has been assessed as unnecessary at this point in time but this needs to be recorded in each residents’ care plan and discussed at their annual health checks. Although there is monitoring for potential complications such as breast and testicular cancer, formal care plans need to be established. As required discussions have taken place with the G.P. regarding capacity to consent and invasive screening. The outcomes now need to be recorded in individual files and if possible confirmation obtained from the G.P. as to the decisions made. There is now improved recording with regard to chiropody appointments and in respect of cholesterol levels. Staff have pursued dental appointments which are not taking place on a regular basis because of a lack of resources. This is fully recorded. A full evaluation of the control and administration of medication will take place at the next statutory visit. Some progress has been made for example drug cupboard keys are now held separate and staff are recording variable dosages. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 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 standard(s) 22 and 23 There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon. There are policies and procedures in place to safeguard service users from abuse. EVIDENCE: Two complaints have been received about the service. As requested these were investigated by the provider. Outcomes were forwarded to the Commission For Social Care Inspection (CSCI). Both complaints were not upheld and the CSCI concurred with the findings. The investigations demonstrated that the provider takes all concerns raised seriously and has a thorough complaints system. There is a copy of the Local Authority vulnerable adult abuse procedures and the Department of Health ‘No Secrets’ guidance available on the premises. As requested the manager stated that a copy of the Protection of Vulnerable Adults (POVA) scheme guidelines had been obtained although these could not be located on the day and a new copy should be obtained. The provider has their own vulnerable adult abuse policy as required. However on examination this requires only slight expansion in order to fully comply with the POVA guidance. It is recommended that the staff disciplinary policy is also amended in light of this guidance. Staff have received vulnerable adult abuse training although certificates are still awaited therefore this recommendation will remain outstanding. A member of staff demonstrated good knowledge regarding vulnerable adult abuse and Whistle Blowing. There is a Whistle Blowing policy in place which includes reference to the CSCI as is good practice. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc 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, 25, 26, 27, 28, 29 and 30 There has been a deterioration in the décor and furnishings in the last 12 months which does not promote a homely environment in which to live. The building and environmental adaptations do not meet the needs of persons with physical disabilities and thereby limits residents’ independence and compromises dignity. Bedrooms and bathrooms do not meet the needs of service users who require wheelchairs or equipment to aid independance. EVIDENCE: In the past concerns have been raised with regard to the building not being entirely suitable for persons with a physical disability. For example there is no overhead tracking. A request was made for this to be considered but unfortunately the structure of the building does not allow for this equipment to be safely fitted. Bedrooms are not all able to easily accommodate portable hoists; as a compromise risk assessments were accepted. There is no storage space for wheelchairs and hoists. The passenger lift will only accommodate one wheelchair user; a member of staff has to squeeze themselves in to a very tight space in order to escort wheelchair users between the floors. Corridors are narrow making turning manoeuvres difficult. As a result plasterwork and bedroom doors have become damaged. Although a new specialist bath was purchased last year staff report difficulties in trying to use the hoist as the 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 17 base of the equipment does not fit comfortably underneath the bath. As a result 3 members of staff are required to assist a resident to bathe. The garden is small and unattractive. The conservatory does not have any blinds or air cooling system. As it is a south facing garden this becomes excessively hot during the summer. An Immediate Requirement was issued in 2003 to cease using this room as temperatures exceeded 58 C. Although some portable fans were purchased and air conditioning system has not been installed. It was very disappointing to see that despite efforts made by the manager, there has been no investment by the provider and as a result this room still cannot be used by residents. Good improvements have been made since the last inspection with regard to the laundry area and infection control procedures. Further improvements are necessary as indicated in the Requirements section of this report. For example although there is a sluice room adjacent to the laundry a wash hand basin should also be installed in the laundry itself. In 2004 a programme of refurbishment was required due to the deterioration in the décor and furnishings; this has not taken place. The unsuitability of the building is recognised by the provider and at the last inspection it was said that a new premises would be built by 2007. However, as at present there has been no further progress with regard to these plans. The standard of décor and furnishings is deteriorating further with a number of stained and worn carpets, worn (and in some cases broken) bedroom and dining room furniture. It was comforting to see that bedroom décor was of a reasonable standard and reflected residents’ personalities. Despite the intention to find a new premises the provider must still ensure that the premises is maintained at a good standard and that residents are provided with a homely environment. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc 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) These standards were not assessed at this inspection. EVIDENCE: There was an evaluation undertaken with regard to progress of outstanding items. As required the manager has now provided information with regard to staffing levels and dependency profiles of service users. It was disappointing to see that the provider has made no progress with providing new staff with an induction and foundation programme that is undertaken by an accredited learning disability awards framework (LDAF) trainer. Although there is a comprehensive induction programme which is run in-house, it is a requirement of the National Minimum Standards and the White Paper ‘Valuing People’ that from April 2002 all new entrants to learning disability should be registered for a qualification on LDAF. Use of this framework can eventually lead to the attainment of a nationally recognised qualification including the new vocational qualifications in learning disabilities. Although the induction programme run by the organisation may well meet the requirements of the TOPSS (The National Training Organisation for Social Care), in learning disability services there is an additional requirement that this be done via a training programme that is approved to offer LDAF. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc 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) 37, 39, 41 and 43 Residents benefit from an extremely well run home. The manager is supported well by her senior staff in providing clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. Service users’ rights and best interests are not safeguarded by the provider’s record keeping policies and procedures. EVIDENCE: The manager demonstrates a supportive and inclusive style of management. As a result staff morale is good and there is a clear commitment to providing a high quality service. Residents benefit from an extremely well run home. For example one resident although admitted more than five months ago was not offered a permanent placement until this week as the manager wanted time to be fully confident that they could meet their needs. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 20 The home is once again failing to keep records on the premises with regard to staff and reports as required by the Care Homes Regulations 2001 17(2), schedule 4. At the last inspection the manager had obtained staff personnel files and was keeping these at the home. These have since been retrieved by the provider and retained at their head office. A personnel data sheet was to be used by the provider with the required information as a compromise, however there was no such record for sessional workers in place. This aspect of the Care Homes Regulations 2001 must be addressed by the service provider to the satisfaction of the Commission for Social Inspection. Some improvements have taken place with regard to fire safety and Legionella since the last inspection. Serious concerns raised in February 2005 have all received satisfactory attention. Staff training will be evaluated at the next visit as training folders containing certificates had been sent to the head office on the day of this inspection. The service provider is failing to comply with the Requirements of the Care Homes Regulations 2001, Regulation 26. Although a senior manager from the organisation is visiting on a regular basis, a written report of the conduct of the home is neither provided to the manager or the Commission for Social Care Inspection. This must be addressed. 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc 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 2 x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 1 1 1 1 1 2 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 34 Pedmore Walk Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x x 2 E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc 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 1 Regulation 6 Requirement To produce the Service User Guide in a format suitable for service users. (Previous timescale of 1/10/03 is partly met). Timescale for action 1/11/05 2. 6 15(1) The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2. The statement of purpose must also include individual measurements of bedroom and communal space. A copy must be forwarded to the Commission for Social Care Inspection (CSCI) upon completion. (Previous timescale of 1/7/05 is not met). To review and expand service 1/11/05 user plans to include goals and objectives relating to all aspects of care including: personal care, social inclusion, community activities, leisure, social care, health care and family contact. (Previous timescale of 1/1/05 is not met). 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 23 3. 9 13(4)(c) 4. 18 12(2) 5. 19 12(1)(a) To introduce a person centred planning process using a recognised format such as essential life style planning and life story books. (Previous timescale of 1/1/05 is partly met). To ensure there are written risk assessments established for all aspects of service users lives which pose a risk, for example: wheelchair use, self harm, use of the passenger lift etc. To ensure care plans contain service users’ observed preferences with regard to cross gender care. (Previous timescale of 1/6/05 is partly met). To make the following improvements with regard to healthcare monitoring and recording: 1) To ensure that service users receive regular audiology tests. (Previous timescale of 1/1/05 is partly met). 2) The Home must introduce a formal procedure in care plans for the monitoring of service users’ health with regard to potential complications such as breast screening, testicular screening through observational checks. (Previous timescale of 1/1/05 is partly met). 3) To undertake a documented discussion with the G.P. regarding service user’s lack of capacity to consent to invasive screening such as mammograms and cervical smears. Outcomes to be included in individual case plans. (Previous timescale of 1/6/05 is partly met). 1/9/05 1/11/05 1/11/05 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 24 6. 20 13(2) 1) To review and update the medication policy to follow good practice identified in the Royal Pharmaceutical Society guidelines for the control and administration of medication issued in June 2003. To forward a copy to the Commission for Social Care Inspection (CSCI). (Previous timescale of 1/6/05 is not met). 2) To continue to progress training for staff in the safe handling of medication from an accredited training provier. To undertake the following improvements to the management of service users’ finances: 1) To ensure that there are two staff signatures obtained for all financial transactions undertaken on behalf of service users. 2) To ensure that contracts are held on individual case files with regard to the 50 contribution of service users’ disability living allowance towards the running costs of the home’s transport. 3) To establish whether the additional weekly payment of £5.00 or £3.00 towards fuel costs is necessary. Or whether the 50 contribution already made by service users covers the costs towards fuel. Documentary evidence must be maintained of discussions with appointees. 4) To investigate why service users are not in receipt of the full total of their personal 1/10/05 7. 23 20(3) 13(6) New Date: 1/11/05 To be reported on at the next inspection) 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 25 allowance from the Local Authority appointee. (Residents finances were not assessed at this inspection). 8. 23 13(6) To expand the vulnerable adult abuse policy to include procedures on the Protection of Vulnerable Adult (POVA) scheme in respect of staff being referred to the scheme on a temporary basis whilst undergoing investigation. To undertake the following improvements to the premises: 1) To provide adequate air cooling systems, ventilation blinds, etc for the conservatory to ensure a maximum temperature is maintained of no more than 24 C – 25 C. (Previous timescale of 20/7/04 is not met). 2) To provide the Commission for Social Care Inspection (CSCI) with a written programme of refurbishment together with timescales for completion. (Previous timescale of 1/9/04 is partly met). 3) To explore the lack of water and low water pressure in first floor bathroom and carry out required repairs. (Previous timescale of 1/9/04 is not met). 4) To replace all stained carpeting in communal areas and bedroom areas. 5) To replace all worn and broken furniture in communal areas (dining room) and 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 26 1/11/05 9. 24 23(2)(p) 1/11/05 individual bedrooms. 6) To carry out written risk assessments with regard to the use of multiple electrical adaptators. 7) To regrout stained tiling in shower room and clean stained tiling in bathroom. 8) To replace stained and worn covering on cradle chair. 9) To replace worn garden furniture. 10) To clean and repair loose paving slabs on patio area. 11) To remove unsuitable signage in service users bedrooms. 12) To repair and make good damaged plasterwork through out the premises. 13) To repair all doors which have been damaged by wheelchair use. 14) To remove staff lockers from the laundry area. 1) To provide induction and 1/10/05 foundation training which meets all of the specifications of the Sector Skills Council which must be carried out within the first six weeks and first six months of employment. To ensure that this is provided by an accredited Learning Disability Awards Framework trainer. (Previous timescale of 1/1/05 is not met) 2) To provide training for staff in equal opportunities and disability equality training. (Previous time34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 27 10. 35 18(1)(c) scale of 1/1/05 is partly met). 11. 12. 37 39 18(1)(c) 24 To ensure that the manager is qualified to NVQ IV in management by 2005. To review and further develop the quality assurance system – to seek feedback from stakeholders, other professionals, families and advocates. (Previous timescale of 1/7/05 is not met). To ensure that copies of criminal record bureau (CRB) disclosures and POVA checks are obtained in respect of the visiting hairdresser and reflexologist. (Previous timescale of 1/5/05 is partly met). To ensure that the hairdresser and reflexologist have appropriate public liability insurance cover. Copies to be retained on the premises as evidence. (Previous timescale of 1/5/05 is not met). To obtain copies of professional qualifications held by the reflexologist. (Previous timescale of 1/5/05 is not met). To obtain and hold information and documents on the care homes premises in respect of persons carrying on, managing or working at a care home as listed in 4 of the Care homes Regulations 2001. To review and expand the Legionella risk assessment. (Not assessed at this inspection). 1/1/06 1/11/05 13. 41 13(6) 19(1)(b) 1/10/05 14. 42 13(4)(c) 15. 42 23(4)(a)( v) To review and expand the fire safety risk assessment. This must cover all aspects of fire New Date 1/11/05 to be assessed at the next inspection 1/11/05 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 28 safety and be specific to Pedmore Walk. (Previous timescale of 1/5/05 is not met). To ensure that there is more consistent weekly testing of the fire alarm system. To ensure all frozen foods are labelled with the dates of freezing. To provide all staff with training in how to manually operate the lift mechanism in the event of a breakdown; this must be fully recorded. To establish written procedures for the lift escape system and disablement of the lift by staff in order to safeguard service users and staff from containment. The Manager must ensure that the business and financial plan for the home is available for inspection. (Previous timescale of 20/5/04 is partly met). To ensure that there is a written report on the conduct of the home completed by the providers representative who is carrying out monthly visits. A copy must be provided to the Registered Manager and a copy forwarded to the Commission for Social Care Inspection. 19. 20. 16. 17. 42 42 13(4)(c) 13(4)(c) 1/9/05 1/10/05 18. 43 25 1/9/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 29 34 Pedmore Walk 1. Standard 23 To ensure that written guidance is obtained with regard to the implementation of the new Protection of Vulnerable Adult Register on 26 July 2004. To ensure requirements and recommendations are fully adhered to. To ensure that all staff receive training in vulnerable adult abuse. To consider fitting a wash hand basin in the laundry room. To consider providing staff with training in tissue viability awareness To ensure that the actual address of the Home is included on the Public Liability Insurance cover certificate or schedule. 2. 3. 4. 5. 30 32 43 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 30 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen 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 34 Pedmore Walk E55 S4794 34 Pedmore Walk V233499 070705 Stg4.doc Version 1.40 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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