Inspection on 24/11/06 for 38 Dagger Lane

This inspection was carried out on 24th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

38 Dagger Lane 01/07/08

38 Dagger Lane 03/09/07

38 Dagger Lane 23/11/05

38 Dagger Lane 29/06/05

38 Dagger Lane 01/03/05

38 Dagger Lane 19/11/04

38 Dagger Lane 01/03/04

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 38 Dagger Lane West Bromwich West Midlands B71 4BE Lead Inspector Mrs Cathy Moore Unannounced Inspection 24th November 2006 07:20 38 Dagger Lane DS0000004770.V321390.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 38 Dagger Lane DS0000004770.V321390.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. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 38 Dagger Lane Address West Bromwich West Midlands B71 4BE 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) 0121 580 0666 0121 580 0752 enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited Samantha Ganderton Care Home 8 Category(ies) of Learning disability (6), Physical disability (8) registration, with number of places 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One service user (female) accommodated at the home may be in the category DE. This will remain until such time that the service users placement is terminated. One service user (male) accommodated at the home may be in the category DE(E). This will remain until such time that the service users placement is terminated. 23/11/05 Date of last inspection Brief Description of the Service: 38 Dagger Lane is an eight bedded nursing home for people with learning/physical disabilities, shares are owned by Care Tec`h The service also provides care and support to two existing residents who have Dementia related needs. The property is situated near to West Bromwich, and has local shops and amenities close by. The home is accessible by public transport and offers on road parking to the front and side and limited off road parking. Accommodation consists of eight single occupancy rooms and communal areas. The home offers shared bathing/toilet facilities as none of the bedrooms are en-suite. Aids and adaptations are provided which meet the assessed needs of the service users. There is a passenger lift available. The home provides a range of in house and community accessed activities, plus a healthcare programme, which utilises various healthcare resources within the local area. The weekly fees for this home range from £1,086.81- £1,600.01. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection on one day between 07.20 and 14.50 hours. The inspection assessed all of the key National Minimum Standards for Younger Adults. Two service users were ‘case tracked’ in detail this process involves looking at their needs and the care that they receive. Other service users files were also examined in less detail. Part of the inspection took place in the lounge/ dining room area where observations could be made on daily routines and staff /service user relationships. The premises were part assessed to include the lounge/dining areas, three bedrooms, the kitchen, laundry, bathrooms and toilets. Three staff were spoken to. Staff files were assessed to look at training and recruitment practices. Records relating to fire safety, quality assurance and servicing of equipment were also looked at. What the service does well: The home is comfortable and homely with a warm welcoming atmosphere. The home is well maintained. Record keeping within the home is good in terms of presentation and maintenance. The home is located in a pleasant area with good facilities close by such as; West Bromwich town centre and Sandwell Valley Park and Farm. Observations of all staff during the inspection showed that they have a very good relationship with the service users. The staff showed patience and respect. They gave attention and time to the people in their care. Service users showed no hesitation in approaching staff with requests or to ask them questions. The home has an effective manager who is well organised, motivated and knowledgeable. The manager gives the required direction and leadership to her staff. Service users are actively encouraged to maintain contact with family and friends. The home has its own transport to enable service users to regularly visit places in the local and wider community. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Prospective service users are generally given information about the home to enable them to make a decision about its suitability. No service user moves into the home without having their needs assessed. Terms and condition documents need to be revised to reflect and meet new legislation. EVIDENCE: A statement of purpose and service user guide was available within the home. Wherever possible, prospective service users are encouraged to visit the home or to have a trial of living at the home before they move in to help them make the decision if the home will or will not be suitable for them. A question asked in Commission service users questionnaires is ‘were you asked if you wanted to move into this home?’. Four service users answered yes to this question one stated that they did not know. One service user commented; “Yes, I was asked by my brother and sister, I had the choice and picked Dagger Lane”. Another question asked is; ‘ Did you receive enough information about the home before you moved in so you could decide if it was the right place for you?’. Three service users answered yes to this question Two answered no. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 9 A completed assessment of need document was included on each service user file viewed. Documentation from the funding authority accompanied the homes’ assessment of need processes. A terms and conditions document was in place for each service user. However, the manager could not confirm whether or not each service user had been assessed in terms of free nursing care contributions. Without this information the terms and conditions cannot be (and are not being) correctly completed as per amended Care Home Regulations 5A (1)-5B (4). 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some ‘fine tuning’ is needed to ensure that care plans in place confirm that they have been produced and reviewed with the knowledge of the service user and that the robust documents concerning risks are clear and legible to support workers. EVIDENCE: A comprehensive care plan was seen on each service users file viewed. These contained a range of needs identified from assessment of need processes examples being; the risk of choking, mobility, transfers and. smoking. It was positive to see that these care plans are being regularly reviewed. There was not sufficient evidence available to confirm that service users are actively involved in the production of their care plans or their subsequent reviews. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 11 Decision making for some of the service users on complex issues due to ability and capacity may be difficult. Observations during the inspection confirmed however that service users are encouraged to make decisions that they can about their lives on a day-to-day basis. Staff continually gave them choices about what they would like to eat at meal times, what they would like to do that day. One staff member was heard asking a service user;” What colour coat do you want to wear when we go out”. Longer term one service user said; “ I am going Christmas shopping soon”. Feedback from completed service users confirmed the following; two stated that they always make decisions about what they do each day, one usually and one never. When asked if they could do what they wanted during the day, evening and weekend all responded as yes. Robust risk assessment were in place covering a range of personal risk issues for each service user examples being; kitchen safety, smoking and daily routines. It was identified that although the risk assessment on service users main files were of a good quality the copies on file for support workers were not as their reproduction made them difficult to read which could place service users at risk. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. Service users are able to take part in age, peer and culturally appropriate activities/ leisure activities in and outside of the home. Service users are encouraged to maintain contact with family and friends. Service user rights are respected. Some development is needed to gain input to be able to evidence that all service users’ are receiving a suitably balanced appropriate diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was ample evidence to show that all service users participate in various activities. Three attend educational facilities on a regular basis. An individual activity plan is produced for each service user on a monthly basis then records are maintained to evidence their participation in the activities planned. One service users activity participation record read; 1/11 indoor 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 13 activities and shopping. 2/11 college. 3/11 drive out. 5/11 chair aerobics. 6/11 college etc. There was evidence to demonstrate that service users have been out on group activities to Sandwell Park and farm and to the Walsall lights. Service users were seen engaging in basic craft activities during the inspection. Then after lunch a number went out shopping. Two service users near to Christmas time 06 are being taken by staff to Minehead Butlins for a disco weekend. The home does encourage service users to maintain contact with family and friends. The home has an open, flexible visiting policy. The weekend following the inspection one service user was going to stay with his family. During the inspection the manager was heard saying to a female service user; “ Your Mum has phoned, she feels a bit tired today but will come and see you tomorrow”. From observations it was clear that routines are based around the needs of the service users. Service users were seen to be getting up at different times during the morning. One rarely gets up until mid morning. Breakfasts were provided individually as service users got up rather than there being a set time. Information on external advocacy services was available for service users and relatives to access if they wish. Breakfast time with the permission of service users up at that time was observed. Staff asked each service user individually what they would like to eat. One chose sugar puffs and a drink, another weetabix. It was positive to see that adapted bowls and cutlery were available and used to aid independent eating. Staff were observed feeding service users who needed to be fed. They sat down and gave the service user time and their full attention. Menus are generally produced weekly with the help of service users. One staff member said; “When choosing menus we sometimes use pictures to help them to understand”. Generally food stocks were plentiful with a good selection of fresh fruit, salad and vegetables. However, many service users at lunchtime had cheese on toast or a sandwich none of which were accompanied by salad. Similarly food intake charts did not demonstrate that fruit and vegetables are encouraged. Neither did they detail in sufficient detail all meals taken for example; one read ‘ takeaway’ and another ‘cheese and potato pie’. The manager confirmed that the menus have not to date been assessed by a dietician. A ‘Five for Life’ leaflet produced by Sandwell PCT was given to the manager informing her of the healthy eating awards and a contact number, as this department are happy to give free advice on menu and meal provision. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 14 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): 18,19,20. Quality in this outcome area is good. The personal care needs of the service users are being met. Improvement is needed in terms of some healthcare access. Medication systems are safe and robust. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans include individual care needs relating to service users. A number of service users are highly dependant. Others are able to care for themselves with support and supervision. Service users with high dependency needs were seen to be appropriately dressed and well cared for. They were wearing age appropriate clothing and their hair was nicely done. Good records are maintained to evidence personal care examples being, hair washes, baths, teeth cleaning etc. One service user was very proud to show the inspector her wardrobe with a range of clothing stored within. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 15 The home is registered to provide nursing care therefore; a registered nurse is on duty at all times. Records viewed showed that a range of health care services is accessed for the service users including chiropody and the optician. However, for one service user there was no evidence that a dental assessment had been carried out recently. During a conversation with the manager it was identified that the continence team has not assessed service users who suffer from incontinence, as they should be for advice on continence aids such as pads. It was positive to find that medication systems are robust and safe. Registered nurses only administer medications. The manger was observed giving medication to one service user. She sat with the service user to ensure that she had taken the medication. The home has a medication policy, which gives instruction on medication ordering, receipt and administration. There were no gaps on medication records meaning that they are being completed properly. Medication totals are carried over to ensure audits can take place. No controlled drugs were being prescribed at the time of the inspection. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 16 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): 22,23 Quality in this outcome area is adequate. Feedback from completed service user questionnaires suggest that some development in terms of complaints procedures is needed. Some ‘fine tuning’ in terms of protection issues is needed to ensure that staff are fully aware of what is expected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints have been received by the home. The Commission has received no complaints about the home. The home has a complaints procedure. It is positive that a part pictorial version is displayed on the wall outside of the manager’s office. One service user was asked what he would do if he had a complaint he said; “ I have not got any. No further information could be gained. Feedback from completed questionnaires suggests that service users need to be reminded regularly about complaints processes as 2 of the 5 stated that they did not know who to speak to if they were unhappy. Similarly 2 of the 5 stated they did not know how to make a complaint. There have been no reported incidents or allegations of abuse. It is positive that the majority of staff, including new staff have received abuse awareness training. However, it is not clear that this training included 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 17 reference to Sandwell Councils referral procedures which should be activated if there was an incident or allegation of abuse. Training records did not demonstrate that all staff have received challenging behaviour training which they should, in case a situation arises. Two service user monies held in safekeeping by the home were checked, money against balances and were found to be correct. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 18 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): 24,25,28,30 Quality in this outcome area is good. Service users live in a home that is generally well maintained, comfortable and safe with bedrooms that suit individual preferences. Shared space is of a generous size, which is comfortable and homely. Some developments are needed in respect of infection control. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is situated in a residential area close to West Bromwich town centre and Sandwell Valley Park and farm. The home is of a generous size. It is generally well maintained, comfortable and safe. The only real decorating need was the pipe work at the back of the toilet situated by the lounge which need repainting. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 19 A discussion was held with the manager about developing a planned refurbishment and replacement programme, as one is not in operation at the present time. The home’s fixtures and fittings are domestic in style creating a homely feel. To enhance orientation within the home – signs on bathroom and toilet doors could be an advantage. An example of where signage would be beneficial is the toilet situated next to the lounge areas. Shared space comprises of a large room made up of three different areas, two dining areas and a lounge area. These are all tastefully furnished and nicely decorated. The home also has a separate lounge where service users can smoke if they want to. Externally, the home has a decent size garden which work has been done on this summer. Three bedrooms were viewed. One service user wanted to show her bedroom herself. Her bedroom was clean and well equipped with modern style furniture. All bedrooms viewed held service users own effects making them homely and individualised. All were of a good standard. The home was found to be clean. No offensive odours were detected. Small improvements are needed in respect of infection control. There was a lack of signs in bathrooms, toilets and the laundry reminding people to wash their hands. Carpets in corridors would benefit from regular deep cleaning as they were stained in places. The kitchen mop was stored in the laundry, as soiled washing is dealt with in the laundry the mop could be at risk of being contaminated by spores. There is a danger then that these spores could be taken into the kitchen on the mop. It is positive that all five of the completed service user questionnaires confirmed that the home was always clean and fresh. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is adequate. Not all staff at the present time are enrolled onto NVQ or LADAF programmes. Careful consideration must be given when decreasing care staff numbers. Staff recruitment processes requires some development to ensure that the service users are fully protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff team on duty at the time of the inspection were very impressive. It was clear that they all had a positive relationship with the service users in their care. They all took time to spend with the service users. They were patient and respectful, there was good eye contact with the service users and they were attentive. Service users observed were comfortable and confident to approach all of the staff on duty to ask them questions. One service user went up to a staff member and gave her a kiss on her cheek. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 21 Staff spoken to were knowledgeable about the service users needs. They all were clearly interested in their work. One staff member said; “ I find my work very rewarding and interesting”. Four of the five completed service user questionnaires confirmed that the staff treat them well, one answered usually to this question. Four of the five completed service user questionnaires confirmed that staff listen and act on what they say, one did not comment. A number of new care staff are yet to be enrolled onto NVQ courses. It is concerning that these staff have not in the interim been commenced onto LDAF training programmes. It was a concern to learn that support staff numbers are possibly being cut from four to three. The home has been functioning to a good standard. A cut in support workers hours can only have a detrimental effect on the quality of service users lives. The home has been operating with four support workers. It is questioned how these can be decreased to three as the numbers and needs of service users have not changed. Generally staff recruitment was of a good standard. Recruitment processes are robust. Interview questions and answers were available on new staff files as was evidence of service user involvement in the interview processes, which is positive. A few shortfalls were identified in that there was a gap in employment history for one staff member but no evidence to show that this had been explored and for staff employed on a POVA first whilst awaiting their full CRB although references had been obtained and a risk assessment carried out there was no evidence to demonstrate that these workers had been allocated a named supervisor as required. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good The manager has been approved as a fit person to run and manage the home. Quality assurance processes are in operation. Health and safety within the home is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission as a fit person to be in charge of run the home has approved the manager. The manager is a Registered Nurse specialising in the area of Learning Disability and has achieved her NVQ level 4 in management. Tt is clear that the manger offers direction and leadership to her staff and demonstrates an ability to run the home effectively. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 23 Quality assurance processes have improved since the last inspection. The manager has issued a range of questionnaires to staff, service users and relatives. These have yet to be published. Regular staff meetings are held to share information and give staff a chance to air their views. It is positive that the service manager is carrying out monthly formal visits to the home and is producing a report of her findings. Since the last inspection an independent consultant has quality assessed the home against the National Minimum Standards for Younger Adults and has published a report of his findings. It is planned for these audits to be carried out twice a year from now on. Health and safety is promoted within the home, random assessment of service certificates and risk assessments was carried out. These were found to be in order. The kitchen was not assessed as it had been recently by Sandwell Environmental Health Department when only one requirement was made. The only concern identified was that the guard on the radiator in the toilet situated next to the big lounge was not secured properly. There were some gaps in staff mandatory training however; the manager is arranging the required training. She is aware of what is needed and has produced a training matrix as evidence. This area will be revisited during the next inspection. 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 3 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 2 34 2 35 2 36 x 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 x 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 3 x x 3 x 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 25 No 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 YA5 Regulation 5(1)(bb) 5B(1)-(4) Requirement The registered person and manager must be able to evidence that all service users have been assessed regarding free nursing care contributions. Fee charges must be specifically detailed on the service users terms and conditions concerning the break down of fees and free nursing care contributions as per the amended Care Home Regulations 5(1)(bb)-5A 16.(b)5B(1)-(4) 2 YA6 15(1) The registered person and manager must ensure that care plans are signed and dated wherever possible by the service user or their chosen representative. This to include care plan reviews. The registered person and manager must ensure that risk assessments on ‘working files’ available to support workers are photocopied to a good standard- as the print was very difficult to read. DS0000004770.V321390.R01.S.doc Timescale for action 10/01/07 10/01/07 3 YA9 13(4)(c) 17(2) 10/01/07 38 Dagger Lane Version 5.2 Page 26 4 YA17 12(1)(a) 16(2)(i) 5 YA17 17(2) Sch 4 (13) 6 YA19 13(1)(b) The registered person and manager must ensure that a dietician or similar assesses the homes menus. ( A contact name and number was given during the inspection that could be used). The registered person and manager must ensure that food intake records are expanded upon to include all food taken for example vegetables and fruit, snacks. The registered person and manager must ensure that the service user identified during the inspection has regular access to a dentist. The registered person and manager must ensure that all service users with incontinence are referred for a continence assessment. The registered person must ensure; That staff are fully aware of Sandwell MBC’s abuse procedures. That abuse awareness training encompasses Sandwell MBC’s abuse procedures. That staff receive challenging behaviour training. The registered person and manager must ensure that the pipes at the back of the toilet room (next to the lounge) are repainted. The registered person and manager must ensure that appropriate signage is used on toilet and bathroom doors. The registered person and DS0000004770.V321390.R01.S.doc 15/01/07 20/12/06 15/01/07 7 YA19 13(1)(b) 15/01/07 8 YA23 13(6) 15/01/07 9 YA24 23(1)(b)(c) (d) 01/02/07 10 YA24 12(4)(b) 05/01/07 11 YA30 13(3) 20/12/06 Version 5.2 Page 27 38 Dagger Lane 23(2)(d) manager must ensure; That the kitchen mop is not stored in the laundry. That corridor carpets are deep cleaned on a regular basis. 12 YA32 18(1)(a) 13 YA33 14 YA34 The registered person and manager must continue to ensure that staff are enrolled onto appropriate NVQ awards (and LDAF) 18(1)(a) The registered person and manager must ensure that adequate staff are provided at all times to meet all service user needs. (Decreasing staff from 4 to 3 is a concern). 19(2)19(11) The registered person and manager must ensure; That prospective staff provide a full employment history to include dates - where there are gaps this should be explored. That where staff are employed on a POVA first that a named supervisor is allocated to that worker. The registered person must ensure; That the unsecured join in the landing carpet is made safe. That the radiator guard in the ground floor toilet is repaired. 10/01/07 15/12/06 20/12/06 15 YA42 13(4)(c) 20/12/06 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 Standard Good Practice Recommendations 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 38 Dagger Lane DS0000004770.V321390.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!