Inspection on 23/05/05 for 34 Walsall Street

This inspection was carried out on 23rd May 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 no outstanding requirements from the previous inspection report, but made 60 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

34 Walsall Street 20/01/09

34 Walsall Street 05/02/08

34 Walsall Street 18/07/07

34 Walsall Street 05/07/06

34 Walsall Street 07/11/05

34 Walsall Street 18/01/05

34 Walsall Street 13/09/04

34 Walsall Street 27/02/04

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 34 Walsall Street Willenhall Walsall West Midlands. WV13 2ER Lead Inspector Lesley Webb Unannounced 23 May 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 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 34 Walsall Street Address Willenhall Walsall West Midlands. WV13 2ER 01902 632211 01902 421941 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) Swan Village Care Services None Care Home 5 Category(ies) of Learning Disability (5) registration, with number of places 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No service users with physical disability aged 18-65 years to be admitted. Date of last inspection 18th January 2005 Brief Description of the Service: 34 Walsall Street is a registered care home for up to five adults, owned by Swan Village Care Services Limited. The home is a large, detached house set it its own grounds situated in a residential area of Willenhall. The local town centre is within easy access, just a short walk away. The home is also situated on bus routes, enabling service users to access the town centres of Willenhall and Wolverhampton. The building consists of five single bedrooms, two of which are located on the ground floor with en-suite shower facilities, lounge, separate dining room, kitchen and laundry. There are also two bathing facilities located on the first floor of the building near to the remainder of bedrooms. On the third floor there is a large room that is not accessed by service users, this is used as a storage facility for the home and the proprietors of Swan Village Care Services Limited. The main aim of 34 Walsall Street is to enable people with learning difficulties to have an Ordinary life. Staff at the home aim to achieve this by encouraging and working with service users to be fully integrated into the community in which they live and to take part in activities according to their individual needs, abilities and interests. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at the home at 1.30pm and stayed until 8.30pm. During that time she interviewed two of the four people who live at the home and all staff who were in the building. In addition to this records were viewed and a tour of the building was undertaken. Since the last inspection the Registered Manager has transferred to another home that the company owns with a senior carer from another home covering this position until the managers post can be filled. On the day of the visit the inspector was informed that the Acting Manager had been on leave for three weeks and a number of senior care staff had been standing in for this person until their return. What the service does well: What has improved since the last inspection? Since the last inspection staff recruitment records stored at the home have improved with only minor work now required in order to fully meet legal requirements. Staff also said that they had undertaken lots of training to help them care for the people who live at the home. Records need to be kept at the home to support these comments. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 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 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 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) Standards not assessed at this inspection. EVIDENCE: 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 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) 6, 7 and 8. Some staffs knowledge of care planning processes is limited resulting in inconsistances in practices. The systems for service user consultation in this home are poor with little evidence that service users views are sought or acted upon. EVIDENCE: Service users that the inspector spoke to were unsure about the contents of their care plans but were able to confirm that monthly meetings occur with their keyworkers and linkworkers where they discuss “how I’m getting on” and “going out different places. Staff that the inspector spoke to confirmed that care plans contain needs and goals but were unable to give examples of these with one member of staff stating, “I don’t really look at the clients files”. The inspector is concerned that if staff do not know the contents of service users plans then the home is at risk of not ensuring all their needs are met in full. In addition to this only one contained evidence that demonstrated six monthly multi-disciplinary reviews taking place. The inspector could find very little evidence that service users are consulted and involved in decisions relating to their own lives and those relating to the 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 10 running of the home. This was particularly concerning as one service user is due to move from the home and asked the inspector if they could find out when this might be happening as they had not been informed. When the inspector looked into this staff stated that there was an issue over transport and who would be funding this. The inspector stated that this should be rectified as soon as possible, and the service user concerned must be kept informed and involved at all times. Staff confirmed that residents meetings occur in order that service users can be involved in making decisions about their lives but when asked how often one person stated, “I think every month” and another, “I don’t know”. The inspector could only find written minutes of one service users meeting, this occurred in February 2005 and detailed discussions around menus, activities and safety. No evidence could be found that issued or requests made by service users having been actioned and addressed. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 and 17. Work must be undertaken to ensure all services user full and varied lives. The home provides a varied menu which enables service users to exercise choice and control over what they eat. EVIDENCE: When asked if they participate in activities outside of the home service users gave examples such as, “ yes we go to the pub, Willenhall town to shop, a disco and to college every Thursday”. One service user stated that they used to go to Albrighton College but that stopped due to “the mini bus not turning up”. When the inspector looked for evidence regarding the mini bus it was found that one service users choices of activities had been restricted, as the companies mini bus does not have a tail lift that would enable them to access this facility in their wheelchair. All service users that the inspector spoke to confirmed that staff help them to keep in contact with their families, either by telephone or arranging visits. One service user was particularly proud to show the inspector their own mobile phone, which enables them to maintain contact with their family. Also all 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 12 service users spoken to stated that the food offered at the home was “nice” with one person stating, “I help get the food ready”. Staff confirmed that service users help purchase, select and prepare meals if they wish. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 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, 19 and 20. Personal support is given in such a way as to promote and protect service users independence and dignity. The health needs of some residents are not being met potentially placing them at risk. Medication practices must improve to ensure the safety of residents. EVIDENCE: All staff that the inspector spoke to demonstrated understanding of individual service users personal support needs. For example one member of staff said, “Each person has preferences with what they want help with, that we respect” and “one person only needs prompting with personal care but another needs full support”. Throughout the day staff were observed treating service users with dignity and respect. After looking at records and talking to service users the inspector was concerned that not all of the health care needs of service users are being met. For example records did not validate that service users receive annual health checks for dentists, hearing and chiropodists. This was particularly concerning for one service user who stated, “my feet hurt when I’m walking, I think it’s because of my nails”. This person then showed the inspector their feet and toenails that were very long, curling under into the person’s toes. The inspector instructed staff that an appointment with a Chiropodist should be 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 14 made immediately to rectify this situation. Since the last inspection nutritional screening has been introduced to ensure appropriate monitoring takes place. The home uses a monitored dosage system for the administration, storing and recording of medicines. In general this was found to be satisfactory apart from signatures missing for a prescribed lotion and no clear administration times for creams. The inspector however was concerned with the practices in place for medication that is administered for the respite facility within the home. Medications are sent to the home without pharmacy instructions and are not in original containers resulting in staff being unsure about the numbers and medication they are signing for. In addition to this secondary dispensing takes place once the medication is received at the home. Risk assessments for self medicating and managing the respite practices must also be introduced within the home. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 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. The home has a satisfactory complaints system with evidence that service users feel that their views are listened to. Improvements to financial records must take place to ensure service users are protected from abuse. EVIDENCE: All the service users that the inspector spoke to were able to name staff that they felt comfortable to talk to if they were unhappy or wanted to complain. When asked why they named specific staff they replied, “because they are easy to talk to” and “because they listen”. Staff who were interviewed also confirmed understanding of the homes complaints procedure and their roles as advocates on behalf of service users wishing to complain. All service users finances and records were checked by the inspector and found to be accurate and up to date. However the inspector found that one service user had paid for a T.V Arial and another for a plate and spoon. The inspector instructed that monies should be reimbursed to the service users, as these items should be provided by the home. Many of the service users at the home also purchase ‘takeaway’ meals from their personal allowance. Records maintained by the home did not demonstrate if this was in addition to three meals provided by the home and/or if the home contributes to this. The inspector said that this must be clarified to ensure service users are not financially abused. Only two of the six staff files sampled contained evidence that staff had undertaken Abuse training. The staff that were interviewed gave examples 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 16 such as, “look for bruises” and “report any changes” as ways they would protect services users from abuse. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 17 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 and 30. Limited improvements to the environment have been made. The outstanding matters do not provide the people living in the home with safe, comfortable surroundings. EVIDENCE: Since the last inspection the home has purchased a new three-piece suite and several areas within the home have been decorated. Upon inspection of the premises further work was found to be required: * Garden furniture must be purchased that meets the needs of the people living at the home. * The lounge carpet needs the stains removing or replacing if stains cannot be removed. * The bottom of the walls need the flaked and scratched paintwork repairing. * The shower in room 2 must be useable. * The extractor fan must be repaired or replaced in the laundry, as the heat in this room is excessive. * Worn or stained bedding used by service users must be replaced. * The uneven slabs around the grounds of the home must be made safe. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 18 In addition to these areas an Immediate Requirement Notice was issued due to a leak in the hallway and for the faulty cooker, both posing health and safety risks to service users and staff that must be addressed as a matter of urgency. Two service users invited the inspector to look at their bedrooms both of which were individually decorated. Whilst in one of the bedrooms the service user pointed out a neighbour who they claimed kept looking in their bedroom. Staff confirmed that the service user had told them about this previously. The inspector instructed that blinds must be fitted to the window to ensure privacy. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 19 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. Reduced staffing levels are impacting on the provision of care provided to people living at the home. Staff need further training and support in order to meet the assessed needs of the people living at the home. EVIDENCE: Records seen by the inspector demonstrated that staffing levels are not being maintained to the agreed levels. When asked why staff stated this was due to serious staffing shortages, with five vacancies on the day of inspection. An Immediate Requirement Notice was issued due to the risk to service users quality of care being received, as no one at the home was able to demonstrate their needs being fully met with the reduced ratios. It was also noted by the inspector that a previous Requirement not to use ‘Tippex’ on staff rotas has not been met and therefore remains outstanding. The inspector sampled six staff training files. All contained staff profiles and individual training assessments, however some required updating. It was also noted that no records were available for staff that had transferred from other homes within the organisation. Staff that the inspector interviewed demonstrated various levels of knowledge relating to the needs of service users and confirmed they had undertaken courses including Adult Protection, 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 20 Crisis Prevention Intervention and NVQ’s. The inspector was therefore disappointed when checking staff records as none of the files sampled contained certificates that substantiated these comments. Staff also stated that they undertake Learning Disability Award Framework accredited training but again no evidence of this could be found. No staff at the home have undertaken communication training specific to the needs of people living there despite this Requirement being identified in a previous inspection. The inspector was shown a training and development plan that requires further development to demonstrate how training will be planned and benefit service users. All staff recruitment files were looked at due to a previous incident where a member of staff had been employed before a satisfactory CRB disclosure had been obtained. Again those staff that had previously been employed in other homes within the organisation did not have the required employment records as listed in Schedules 2 and 4 of the Care Homes Regulations 2001. Other staff files contained more information but not all required by legislation. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 21 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, 42 and 43. There is no consistant leadership, guidance and direction for staff to ensure service users receive consistant quality care. This results in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: Everyone that the inspector spoke to stated the running of the home has been affected since the Registered Manager has left with staff “unsure” of whom to turn to for advice. The inspector feels that the number of Requirements identified in this inspection demonstrates that the home is not being managed effectively and Swan Village Care Services should proactively recruit a new manager to ensure that a quality service is maintained. No one at the home was able to show the inspector a quality assurance system therefore all Requirements identified in previous inspections relating to this 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 22 remain outstanding. The inspector feels this is another example of poor management within the home. When looking around the building the inspector found that five cupboards in the kitchen are kept locked and was informed that this was due to “knifes being stored in there”. The inspector was informed that a written assessment of this practice was in place. The inspector instructed that the home must look at alternatives that do not restrict service users freedom of choice whilst maintaining their safety. The inspector found it very difficult to ascertain if staff have undertaken training in food hygiene, first aid, moving and handling, health and safety, infection control and fire due to poor recording systems (see Standard 32 and 35) and therefore Requirements relating to training remain outstanding. In addition to this none of the staff on duty were able to confirm that they held up to date certificates in these areas. Risk assessments were found to be in place for all safe working practices. COSSH assessments were inspected. These were found to be incomplete and did not detail particular brands e.g. they stated floor cleaner but not which brand. A previous Requirement to provide a financial plan for the home remains outstanding. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 23 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 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 2 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 2 2 x 2 Standard No 11 12 13 14 15 16 17 x 2 2 x 3 x 3 Standard No 31 32 33 34 35 36 Score x 2 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 34 Walsall Street Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 1 x 2 2 2 E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 24 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. 2. Standard YA6 YA6 Regulation 15 15 Requirement Staff must be aware of the contents of service users care plans All residents must have six monthly multi-disiplinary review meetings to review their care plans The home must develop service user care plans in order that they clearly detail the primary care needs (as listed in Standard 2) The home must be able to demonstrate that service users are involved in monthly key worker meetings Residents meetings must occur monthly with minutes maintained Decisions made in response to residents requests and agreed at residents meetings must be carried through or reasons for not doing so must be documented The service user who is due to move from the home must be kept fully informed of this process including a date for moving The service user who is due to Timescale for action 31/07/05 31/07/05 3. YA6 15 31/07/05 4. YA6 15 31/07/05 5. 6. YA7 YA7 12(2) 12(2) 31/07/05 31/07/05 7. YA7 12(2) 31/05/05 8. YA7 12(2) 31/05/05 Page 25 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 9. YA8 12(2) 10. YA8 12(2) 11. 12. YA12 YA13 16(2) 16(2) 13. YA19 12(1) 14. 15. YA19 YA19 12(1) 12(1) 16. YA20 13(2) 17. YA20 13(2) 18. YA20 13(2) 19. YA20 13(2) move from the home must be informed of the transport arrangements that will facilitate the move The home must involve service users in the day to day running of the home, and development and review of its policies and procedures The home must be able to demonstrate that service users are involved in the recruitment and selection of new staff The home must ensure all service users have opportunities for further education The home must ensure transport is availible for wheelchair users to access the community, activities and further education establishments All service users must be offered minimum annual health checks for vision, medication and hearing All service users must be offered regular chiropody appointments The service user with toe nails that are causing pain must receive immediate attention from the relevant specialist All prescribed medication, including creams and lotions must be signed for when administered Clarification for the administration times for creams and lotions must be sought from the pharmacist Risk assessments must be completed that demonstrate if service users are able to self medicate and what support is needed if any A risk assessment must be completed for the medication practices for the respite service user 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/05/05 31/05/05 31/05/05 31/07/05 31/05/05 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 26 20. YA20 13(2) 21. YA23 10(1) 22. YA23 10(1) 23. YA23 10(1) 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. YA23 YA23 YA24 YA24 YA24 YA24 YA24 YA24 YA26 YA26 10(1) 10(1) 16(1) 16(1) 16(1) 16(1) 16(1) 16(1) 16(1) 16(1) Respite mediation must be handled according to the requirements of the Medicines Act 1968 and following guidelines from the Royal Pharmaceutical Society of Great Britian Service users must be reimbursed for purchasing their own T.V. ariel and plate and spoon The home must maintain records that demonstrate service users receive three main meals as part of their contract fee and if one of these is a Takeaway meal that this is funded by the home The home must implement a written policy that details what service users must contribute out of their personal allowances towards Takeaway meals. Records of service users meals must include Takeaways and who funded these All staff must undertake Abuse training with certificates maintained at the home The lounge carpet must be cleaned or replaced if the stains cannot be removed The flaked and scratched paintwork in the lounge must be redecorated Garden furniture appropriate to the needs of the people living at the home must be purchased The uneven slabs around the home must be made safe The leak in the hallway must be addressed The cooker must be replaced Blinds must be fitted in N bedroom Risk assessments must be completed for any faulty items of furniture, equipment or facilities 31/05/05 31/05/05 31/05/05 31/05/05 31/05/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/05/05 31/05/05 31/05/05 31/05/05 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 27 within the home 34. 35. 36. YA26 YA30 YA32 16(1) 13(3) 18(1) The shower in room 2 must be usable The extractor fan in the laundry must be repaired or replaced All staf must undertake communication training relevant to meeting service users needs (REQUIREMENT ORIGINALLY MADE JANUARY 2004) All staff must hold a care NVQ 2 or 3 or be working to obtain one by an agreed date A minimum of three staff must be on duty during the hours of 7am and 9pm, seven days per week, with addition staff when the respite bed is used Assessments of service users needs and individual care staffing hours that are funded by the relevant placing authorities must be forwarded to CSCI The numbers and skill mix of staff on duty must ensure the following activities are carried out effectively:- uninterrupted work with individuals, administration, organisation and communication, day to day running of the home and management of emergencies A minimum of six staff meetings a year must occur with minutes maintained and actioned The staff rotas must be expanded and include details of when service users are out of the home and time spent on domestic duties by staff A recruitment documentation as detailed in the Care Homes Regulations 2001 must be in place for all staff working at the home prior to them commencing shifts Staff who work at other homes 31/07/05 31/07/05 31/07/05 37. 38. YA32 YA33 18(1) 18(1) 31/07/05 31/05/05 39. YA33 18(1) 23/06/05 40. YA33 18(1) 31/07/05 41. 42. YA33 YA33 18(1) 18(1) 31/07/05 31/07/05 43. YA34 Schedules 4, 6 31/07/05 44. YA34 19 31/07/05 Page 28 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 45. YA35 18(1) 46. YA35 18(1) 47. YA35 18(1) 48. YA35 18(1) 49. 50. YA35 YA37 18(1) 9 51. YA37 9 52. YA39 24 53. YA39 24 within the organisation must have copies of their recruitment documentation maintained within the home The training and development plan for the home must include details of when staff will obtain training they require Certificates must be maintained at the home for staff who have undertaken equal opportunities training A training needs assessment must be carried out for the staff team as a whole, and an impact assessment of all staff development undertaken to identify the benefits for service users (REQUIREMENT ORIGINALLY MADE JANUARY 2005) The home must be able to demostrate that staff use Learning Disability Award Framework (LDAF) accredited training Staffs individual training assessments must be updated regularly An application to register a permanent, appropriately qualified and experienced manager must be submitted to CSCI Until such time that a manager is recruited to the home, the Acting Manager must work supernumary hours to those of care staff An internal audit of the quality assurance sytem must take place at least annually (REQUIREMENT ORIGINALLY MADE JANUARY 2005) An annual development plan for the home must be implemented (REQUIREMENT ORIGINALLY MADE JANUARY 2005) 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/05/05 31/07/05 31/07/05 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 29 54. YA39 24 55. YA41 17 56. YA42 13(3-6) 57. YA42 13(3-6) 58. YA42 13(3-6) 59. YA42 13(3-6) 60. YA43 25 The results of service user, families and stakeholders in the community surveys and questionnaires must be published and made available to all interested parties including the CSCI (REQUIREMENT ORIGINALLY MADE JANUARY 2005) Tippex must not be used on staff rotas (REQUIREMENT ORIGINALLY MADE JANUARY 2005) COSSH sheets must be implemented for all products used within the home. These must detail particular brand names All staff must hold up to date food hygiene, first aid, moving and handling and infection control certificates, with records maintained at the home for inspection (REQUIREMENT ORIGINALLY MADE JANUARY 2005) All staff must undertake two fire training sessions per year, with certificates maintained within the home A risk assessment must be completed for the locks on the kitchen cupboards and alternative practices explored A financial plan for the home must be availible for inspection (REQUIREMENT ORIGINALLY MADE MARCH 2003) 31/07/05 31/05/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 61. 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 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 30 34 Walsall Street 1. 2. Standard YA13 YA35 It is recommended that the home purchase its own transport that meets the needs of the people living at the home Consideration should be given to expanding the individual training and development plans as presently they do not allow for developmental needs that do not require formal training to be recorded 3. 34 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 31 Commission for Social Care Inspection West Point Mucklow Office Park 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 Walsall Street E55 S20850 34 Walsall St V229173 230505 Stage 4.doc Version 1.30 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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