Inspection on 05/02/08 for 34 Walsall Street

This inspection was carried out on 5th February 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 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 18/07/07

34 Walsall Street 05/07/06

34 Walsall Street 07/11/05

34 Walsall Street 23/05/05

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 27/09/2008.

CARE HOME ADULTS 18-65 34 Walsall Street Willenhall Walsall West Midlands WV13 2ER Lead Inspector Dawn Dillion Key Unannounced Inspection 5th February 2008 10:25 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 34 Walsall Street Address Willenhall Walsall West Midlands WV13 2ER 01902 632211 01902 632211 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Swan Village Care Services Limited Vacant post Care Home 5 Category(ies) of Learning disability (3) registration, with number of places 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service users with physical disability aged 18-65 years to be admitted. 18th July 2007 Date of last inspection Brief Description of the Service: 34 Walsall Street is a registered care home located in Walsall, West Midlands and provides a service for five people who have a learning disability; one person accesses the service on a respite basis. The home is situated in walking distance from Willenhall Town, having easy access via public transport to Walsall Town Centre. 34 Walsall Street is a large detached property, which comprises of five single occupancy bedrooms, two of which are located on the ground floor, having en suite facility and the remaining three situated on the first floor equipped with a washbasin. Two bathrooms are located on the first floor; there is a stair lift in place, to enable one person living in the home to access their bedroom. A lounge area is provided on the ground floor, equipped with essential furnishings and fitments, where individuals are able to relax or socialise with other people living in the home. The home also provides a small dining area, a domestic style kitchen and a laundry. People using the service also have access to a private garden area at the rear of the property. Very limited car parking is available within the garden area. Staffing is provided on a 24-hour basis, to ensure the total supervision and support of people living in the home. People living in the home had access to relevant healthcare services. The fees chargeable for the service provided at 34 Walsall Street are from £483.00p - £1,130.00p per week. This information was correct at the time of this inspection. The reader may wish to contact the service for more up to date information. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 5 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The unannounced Key Inspection of 34 Walsall Street was undertaken within six hours. The inspection methodologies that were used to ascertain the quality of the service delivery and peoples experience of living at the home entailed the examination of the homes policies and procedures that demonstrated practices with regards to equality, diversity and the promotion of normal daily living to ensure social inclusion. People that use the service and staff members were interviewed during the process of the inspection, to establish their views and opinion. An inspection of the premises was also conducted to ensue that the environment and systems in place were suitable to meet the needs of people living in the home. What the service does well: What has improved since the last inspection? As previously identified there has been a marked improvement with information contained within the support plans and evidence of the intervention of relevant healthcare professionals, to monitor the individuals general health. More attention was now focused on all peoples cultural and religious needs to enable the individual to live a lifestyle of their choice. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 7 Records relating to the support provided to people suffering with diabetes and the intervention of a specialist Diabetic Nurse was now evident. 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. The summary of this inspection report can be made available in other formats on request. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to access the service are provided with the necessary information to enable them to establish whether the service can meet their needs effectively. EVIDENCE: The Statement of Purpose and the Service User Guide was a combined document that provided relevant information to enable people wishing to access the service, to make an informed choice to whether the home would be suitable to meet their needs. These documents were available in plain English, Punjabi and pictorial format to promote the understanding of people using the service. There had been no new admissions to the home in recent years; discussions with the Care Manager identified that any further admissions to the home would be subject to a Care Management Assessment and routine trial visits prior to a placement being offered. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 10 The home provided a respite service for one person on a regular basis, discussions with staff and the examination of records identified the need to re assess the service provided to this individual, to ensure that their needs were being met effectively to guarantee the persons safety and welfare. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with the necessary support to live a lifestyle to reflect their cultural and religious needs. Risk assessments do not necessarily provide the opportunity to enable the individual to take an informed risk but in one case restricted the freedom of movement, having a negative impact on the person’s rights and choice. EVIDENCE: Two support plans were randomly selected for examination, it was pleasing to see that the support plans had been reviewed to provide more comprehensive information, relating to the care needs of the individual, the level of support 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 12 and assistance required to promote the persons independence and also identifying the relevant intervention of other healthcare professionals. Support plans were reviewed on a timely basis to reflect the changing needs of the individual. It has been identified as a recommendation within the contents of this report that people living in the home should be encouraged to participate in the development and review of their support plan. People living in the home were encouraged to participate in decision making, through the process of meetings. The minutes of one meeting identified discussions relating to menu choice and events within the home, the minutes were printed in a pictorial format, to promote the understanding of people living in the home. Risk assessments were incorporated within the support plan, providing information relating to the assistance the individual required and any potential hazards involved in promoting people’s independence, enabling them to take an informed risk. Discussions with staff and information contained within a risk assessment identified the need to keep a bedroom door closed to prevent a person leaving their room due to the risk of them falling down the stairs. It is of concern that no consideration was given to the affect this may have on the individual with regards to their lack of freedom of movement and the infringement of the person’s rights. The examination of the identified persons support plan, risk assessment and discussions with staff evidenced that the home were not appropriately equipped to meet the needs of this person. We acknowledge that the home had sought assistance/advice from the placing Local Authority; however, a contingency plan should be put into place, to ensure the safety and welfare of this person during this period. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is conducted in a manner to ensure that people were able to access leisure services, to enable the individual to have community contact and a valuable place within society. The lack of provisions and staff practices could have a negative impact in promoting the privacy and dignity of some people living in the home. EVIDENCE: Discussions with people that live in the home, the Care Manager and general observations during the process of the inspection, confirmed that one person attended college on a full time basis, undertaking training to enhance their daily living skills, to promote the individuals independence. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 14 The Care Manager informed us that the home was currently waiting for funding for a day care placement in respect of another person living in the home. Staff assisted people to pursue social activities of their choice. Individuals were actively involved in shopping for provisions for the home. People accessing the service at 34 Walsall Street were not engaged in paid employment, discussions with the Care Manager confirmed that people who accessed the service did not have the capacity to do so. The home provided a service for two people from the ethnic minority group; one person was given the necessary assistance to attend the local temple on a regular basis, to enable them to continue to practice their religious faith and to maintain contact with their cultural beliefs. The Care Manager informed us that the remaining people living in the home would attend church if and when they so wished. The Care Manager also informed us that people living in the home had access to a self-advocacy service. The staff provided the necessary assistance and support to enable people to access leisure services within their local community. Discussions with people living in the home confirmed that they were able to maintain contact with their family and friends. On the day of the inspection the daily routine within the home appeared relaxed with people having freedom of movement, pursuing their own pastimes, for example watching television and doing craft work. Staff were observed to interact with people in a professional manner, communicating with the individual in a mode suitable to their understanding. The home continues to provide a respite service for one person on a regular basis, the previous inspection report identified concerns of the homes lack of capacity to meet this persons needs effectively. It remains a concern that the home does not have the facilities to meet this persons needs. The practice of a female accessing the bedroom of male to use his en suite continues with very little emphasis focused on the individual’s privacy or dignity. The examination of minutes of meetings identified that people were involved in the development and review of the menus to reflect the individuals likes, dislikes and to also incorporate special diets in relation to people’s health, cultural and religious needs. The Care Manager confirmed that she was currently liaising with the Community Nurse regarding the dietary needs for people suffering with diabetes, information of which would be incorporated within the menu. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of people’s identified needs are met in accordance to the support plan. The lack of a contingency plan during the assessment period for one person has a negative impact on the delivery of the care and infringes the privacy and dignity of other people living in the home. EVIDENCE: There was a marked improvement with information contained within the support plan, identifying the care needs of the individual and the level of support and assistance the individual required to promote their wellbeing and 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 16 independence. The support plans were reviewed in a timely manner to reflect the changing needs of the individual. People living in the home had access to relevant healthcare services and it was pleasing to see that people suffering with diabetes, now had regular access to a Diabetic Nurse, to monitor their health and to provide professional support to the individual and to the staff. Records that were examined evidenced that people were offered the opportunity of having an annual health check. Information relating to the individuals dietary needs, communication skills and continence management was also incorporated within the support plan. As previously identified within the contents of this report, risk assessments were incorporated within the support plan. More emphasis needs to be focused on promoting the individuals privacy and dignity, it was identified that peoples personal care needs were not always catered for within the privacy of their own bedroom, (please refer to outcome group Lifestyle). With regards to personal support, people living in the home were able to retire to bed and awake as they so wished within the realms of participating in planned daily activities. There was recognition of peoples cultural and religious needs and people living in the home benefited from a mixed ethnic staff group. With reference to the homes medication practices, the home operated the Nomad monitored dosage system. ‘When required’ medicines were in use for a number of people. The Care Manager should ensure that a protocol for the use of these medicines is in place for everybody who have been prescribed medicines to take on a ‘when required basis.’ To ensure that staff are aware of when these medicines should be administered, the dosage, intervals and what actions should be taken if the drug is not effective. The Care Manager informed us that all staff who were responsible for the administration of medicines had received Safe Handling of Medicines training. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are able to express their concerns/complaint using the homes complaint procedure, which is accessible through various formats to ensure that the peoples concerns are addressed. The homes recruitment procedure and practices ensure the protection of people accessing the service. EVIDENCE: The homes complaint procedure was incorporated within the homes Statement of Purpose and Service User Guide, which was accessible to people living in the home. We have not received any concerns/complaints about 34 Walsall Street in recent months. Discussions with the Care Manager and the examination of records confirmed that the home was in receipt of various safeguarding policies pertaining to the funding authority of individuals living in the home. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 18 There had been no new recruitments since the last inspection visit, the previous inspection report identified that the homes recruitment procedure incorporated the necessary safety checks, to ensure that people living in the home were protected from abuse. People living in the home required some element of support with the management of their financial affairs. Three records and funds were examined and found to be satisfactory. Receipts were maintained for all financial transactions. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The layout and design of the property is not suitable to meet the needs of all people accessing the service. The accommodation provides very little stimulation, comfort or privacy for people living in the home. EVIDENCE: 34 Walsall Street is situated in Walsall, West Midlands and is located within walking distance from Willenhall Town, having easy access via public transport to Walsall Town Centre and Wolverhampton City Centre. The large detached property was in keeping with the local community, the home comprised of five single occupancy bedrooms, two of which were located on the ground floor, having en suite facilities and the remaining three situated 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 20 on the first floor were equipped with a washbasin. Furnishings within the bedrooms were worn and tired looking. It was pleasing to see that the necessary measures had been taken to replace the chest of drawers in a previously identified bedroom. The carpet in one bedroom was old and stained. One bedroom was allocated for a respite service, this room was sparse, institutional and the furnishings were old. The lighting within bedrooms was poor. Discussions with the Care Manager and general observations of one bedroom identified that insufficient furnishing was provided to enable the person occupying this room to be able to store their clothes appropriately. It is of concern that a bed was situated close to an unguarded radiator, due to the persons health condition this posed a risk of burns from the hot surface. On the day of the inspection the radiator was very hot to the touch. Two bathroom/shower rooms were located on the first floor, which were sparse and institutional, offering no home comforts at all. One toilet was situated on the ground floor and was accessible to people living in the home. There was a stair lift in place, to enable one person using the service to access their bedroom. A lounge area was provided on the ground floor, this area had recently been painted and fitted with new flooring. Since the last inspection visit a new settee had been purchased to provide more comfort to people living in the home. The home also provided a small dining area, a domestic style kitchen and a laundry area. The laundry was equipped with a washing machine and a dryer; there were no sluicing facilities available. Discussions with the Care Manager confirmed that there was an issue of continence management within the home. The Care Manager should ensure that all COSHH (Control of Substances Hazardous to Health) chemicals are stored securely within the laundry to ensure the health and safety of people living in the home. During the tour of the property it was noted that insufficient heating was provided in the dining room and one bedroom. The home was also experiencing problems with the water system, where there was a lack of hot water supplies, the homes records identified temperatures as low as 34.3 degrees in the bathroom located on the first floor. The Care Manager was also not aware of whether the bath had been fitted with a thermostatic control valve. An immediate requirement was issued on the day of the inspection. The cleanliness of the home was of a satisfactory standard with the exception of one bedroom. Discussions with a staff member confirmed that the 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 21 individual was encouraged to maintain the hygiene standards within their bedroom. People using the service also had access to a private garden area at the rear of the property, on the day of the inspection it was noted that old furnishings had been disposed of in the garden. Very limited car parking was available within the garden area. The homes Statement of Purpose stated that, “All houses are equipped to an extremely high standard and interiors can be altered or modified to meet the individual needs/preference of the individual service user.” 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a structured and skilled staff team to ensure that their needs are met affectively in accordance with their assessed needs. EVIDENCE: The examination of staff rotas and discussions with the Care Manager confirmed that sufficient staffing levels were provided to meet the needs of people living in the home. The working rotas were flexible to accommodate various activities within the day and also the number of people in residence at any one given time. The Care Manager informed us that all staff with the exception of one had obtained the National Vocational qualification level 2 or 3. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 23 Records that were examined evidenced that staff undertook periodical training pertaining to their roles and responsibilities. It is pleasing to see that with reference to a recommendation identified within the previous inspection report, staff had now received training in communication, to enable them to communicate more effectively with individuals who have limited verbal skills. As previously identified within the contents of this report, the home had not had any new recruits since the last inspection visit, at the previous inspection we identified that the homes recruitment procedure incorporated the necessary safety checks to ensure the protection of people living in the home. There was a positive emphasis focused on providing staff with regular supervision, to ensure that they receive the necessary level of support and guidance. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The open, transparent management style recognises the short falls within the service delivery and the need for improvement, to ensure the health and welfare of people accessing the service. EVIDENCE: The Care Manager was appointed on 17 September 2007, and had not yet submitted an application for registration, however she confirmed that she was in the process of collating the necessary information to submit her application. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 25 The Care Manager had vast experience in social care and had also obtained the necessary qualifications pertaining to her roles and responsibilities and also undertook periodical training to keep abreast of issues relating to social care. Discussions with the Care Manager identified her knowledge and understanding of the short falls within the service and she appeared enthusiastic in promoting the health and welfare of people accessing the service and to provide a more effective service delivery. A quality assurance and improvement plan was in place to monitor the service delivery. Monthly audits were also conducted covering areas such as, healthcare, accidents, staffing, complaints and environmental factors. There were a number of short falls identified during the course of the inspection, which included insufficient heating and hot water supplies within the home that needs to be addressed as a matter of urgency. Discussions with the Care Manager confirmed that she was in the process of developing an evacuation plan in respect of the individual, to ensure that staff were provided with information, relating to the level of support and assistance that would be required to enable the person to evacuate the building safely in the event of a fire. The examination of the fire inspection report and discussions with the Fire Safety Officer, confirmed his satisfaction that recommendations that were identified had now been met accordingly. The Care Manager had developed a risk assessment with regards to a canopy that had recently been built by the fire exit. It was noted on the day of the inspection, that control measures identified within the risk assessment, to ensure that this exit was clear from obstruction had not been adhered to by staff. Records that were examined evidenced routine checks/servicing of gas and electrical systems and appliances. 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 1 27 1 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 2 2 X X 2 X 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 27 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 YA30 Regulation 23(2)(k) Requirement The lack of a sluicing facility compromises the management of infection control. The registered person is required to provide suitable systems to prevent cross contamination. (Outstanding requirement from 30/10/07). Furnishings within the home 31/05/08 are old, worn and many are in a state of disrepair. The registered person is required to take the appropriate actions to ensure that people living in the home are provided with suitable and functional furnishings. (Concerns relating to the general maintenance, decor were also identified within the last inspection report. The previous timescales were 31/08/06 and 25/09/07 and 01/02/08). 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 28 Timescale for action 01/05/08 2. YA24 23(2)(c) and 16(2)(c) 3. YA42 13(4)(a) Water temperatures accessible to people living in the home are not consistent. The registered person must ensure that the appropriate measures are undertaken to ensure an ambient temperature of 43oC. (Outstanding requirement from 30/08/07 and 31/01/08). An immediate requirement was issued on 05/02/08. 05/02/08 4. YA16 12(4)(a) The practice of assisting a female to access of male’s bedroom to use his en suite facilities demonstrate a lack of respect of the individual’s rights, privacy and dignity. The registered person is required to address these poor practices to preserve the rights of people accessing the service. (Outstanding requirement from 18/08/07 and 31/01/08). 20/04/08 5. YA37 8 The Commission for Social Care Inspection have not received an application to register the Care Manager The Registered Providers must take the appropriate actions to ensure that the Care Manager is registered. 01/05/08 6. YA2 14(a)(2)(a)(b) The home is unable to demonstrate that they can meet the needs of a person DS0000020850.V358830.R01.S.doc 20/04/08 34 Walsall Street Version 5.2 Page 29 accessing the service. The registered person must take the necessary actions to ensure that an assessment is carried out. Remains outstanding from 21/01/08. 7. YA24 23(2)(p) The lack of sufficient heating and lighting within the home compromises the welfare of people living in the home. The registered person should take the appropriate actions to ensure that sufficient heating and lighting is provided throughout the home. (Outstanding from 31/01/08). An immediate requirement was issued on 05 February 2008. The carpet in an identified bedroom is rippled and poses a tripping hazard. The registered person must address this to ensure the safety of people accessing this room. (Outstanding from 31/01/08). 09. YA42 23(4)(b) The registered person should take the necessary actions to ensure that staff adhere to the fire risk assessment, to ensure the safety of people accessing the service. There are inconsistencies in ensuring that written protocols are in place for the use of ‘when required’ DS0000020850.V358830.R01.S.doc 05/02/08 08. YA42 13(4)(a) 20/04/08 20/04/08 10. YA20 13(2) 20/04/08 34 Walsall Street Version 5.2 Page 30 medicines. The registered person must take the appropriate measures to ensure that a protocol is in place, to guide staff as to when these medicines should be administered, at what intervals, dosage and what action should be taken if the drug is not effective. A risk assessment pertaining to one person raises concerns to the lack of freedom of movement and the infringement of this individual’s rights and choice. The registered person must ensure that the necessary measures are taken to promote the general welfare and safety of the identified person. The radiator located in the identified bedroom is not guarded and does not protect the person occupying this room from the hot surface. In view of this person’s health condition, the registered person must take the necessary action, to ensure that this person is protected from the hot surface. During the assessment period for the identified individual. The registered person should ensure that the appropriate measures are taken to ensure the safety and welfare of this person during the interim period. 11. YA9 12 20/04/08 12. YA24 13(4)(a) 20/04/08 13. YA9 13(4)(a) 20/04/08 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations To consider strategies for promoting residents’ dignity during meals and mealtimes, for example tablecloths, condiments. People living in the home should be involved in the recruitment and selection of staff. The alternative choice identified on menus should have the same nutritional value as the main choice. The identified person should provide with the necessary level of support to maintain the hygiene standard within their bedroom. People living in the home should be encouraged to participate in the development and review of their support plan. To ensure that all COSHH (Control of substance hazardous to Health) is maintained securely. 2. 3. 4. 5. 6. YA8 YA17 YA30 YA6 YA42 34 Walsall Street DS0000020850.V358830.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000020850.V358830.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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