CARE HOME ADULTS 18-65
38 Dagger Lane 38 Dagger Lane West Browwich West Midlands B71 4BE Lead Inspector
Patrick Wright Announced 29 June 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. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 38 Dagger Lane Address West Bromwich West Midlands B71 4BE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 580 0666 0121 580 0752 N/A Lonsdale (Midlands) Limited Samantha Ganderton Care Home 8 Category(ies) of Learning Disability (LD) - 6 registration, with number Physical Disability (PD) - 8 of places 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 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 2. 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 Date of last inspection 1 March 2005 Brief Description of the Service: 38 Dagger Lane is an eight bedded nursing home for people with learning/physical disabilities, and is owned by Lonsdale Midlands Ltd. The service also provides care and support to two exisiting 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. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was conducted over 4 hours, and was a statutory announced inspection of which the home had approximately six to eight weeks notice. The purpose of the inspection was to assess progress and compliance in meeting the National Minimum Standards and towards addressing items identified at previous inspection visits. A range of inspection methods was used to make judgements and obtain evidence, which included discussion with the acting manager and one of the qualified nurses. There was also a brief tour of the ground floor premises, and rear garden. Bedrooms were not seen on this visit as a tour of the premises took place during the last inspection. There are eight service users currently living at 38 Dagger Lane. The home is registered to provide nursing care for adults with learning and physical disabilities, and other complex needs. Some service users were involved in various community activities during the inspection. Five of the service users were present during the inspection, but formal interviews were not appropriate. Therefore the inspector relied upon body language, responses and other observations of interaction between staff and residents. A number of records and documents were also examined. Other information was gathered prior to the inspection, which included the pre-inspection questionnaire, feedback from relatives, and one resident filled in a questionnaire. Service users who were observed/spoken with during the inspection appeared satisfied with the quality of care provided. Overall the home has a comfortable and relaxed atmosphere. The Registered Manager of the service was on extended leave when this inspection took place. The acting manager was present and is fully involved in the day to day running of the home. What the service does well:
38 Dagger Lane provides a homely environment for service users and offers choice and a good level of care. The home offers support to a group of individuals with a range of complex needs and strives to promote ordinary living principles and include social inclusion in their lifestyle. Each service users’ file is well maintained and continues to provide a range of comprehensive individual plans of care incorporating specialist requirements and procedures designed to meet the needs of the person. The comprehensive care planning system assists staff and supports service users. The home uses and continues to develop a risk assessment system with interventions and guidelines for staff clearly described.
38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 6 The home is run by a professional enthusiastic management and staff team, with a clear emphasis on service users expressing their own personalities and encouraged to make choices and decisions regarding their daily lives. Staff support residents to enjoy a wide range of community based and in-house activities, which are geared towards their own wishes and needs. Service users can choose what they want to eat and staff make efforts to help residents to make their preferences known through different methods. As a specialist service for people with a learning disability, 38 Dagger Lane continues to be able to demonstrate it offers care based on current good practice and reflects professional and clinical guidance. This statement is based on relevant discussion, observations, and through evidence in the form of information, documentation/records supplied at this inspection and progress made following previous inspections. Relatives who returned a questionnaire stated that they are kept informed of important matters and were aware of how to complain if unhappy. Also they said they are made to feel welcome at the home and can speak with their relative in private if they wish. What has improved since the last inspection? What they could do better:
With the exception of several minor shortfalls the home is meeting the majority of the National Minimum Standards for younger Adults.
38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 7 With this in mind the home needs to ensure that the current service is maintained and progressed with regard to further good practice initiatives. For example building on the work that has already started to produce Lifestory books and adopting an essential lifestyle system of person centred planning. Maintaining a multi agency approach is also an important factor to demonstrate the service is not making decisions in isolation with regard to the care and support of vulnerable adults. This may be with regard to highlighting changes in the needs of service users, with the relevant community teams or worker and agreeing on the best way forward. Staff would also benefit from routinely revisiting their personal roles and responsibilities, for example with regard to policies and procedures. One relative who returned a comment card stated that they felt there was not always sufficient staff on duty at the home, but did not provide a contact name for this to be followed up. One of the service users stated they would like to be more involved in the running of the home. 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. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 The homes admission procedure ensures there is a proper assessment conducted prior to people moving into the service. EVIDENCE: The home adopts the `Activities of daily living skills` assessment tool, used in conjunction with information supplied by relevant professionals involved in the placement. At the time of inspection there were no service user vacancies. In the future the assessment process will include issues of compatibility, and whether the home is an appropriate place for someone who is a younger adult. The acting manager is aware that new service users should be admitted to Dagger Lane only on the basis of a full assessment, which involves the service user and meets the requirements of standard 2.2 of the National Minimum Standards for Younger Adults. The home will secure `Care Management` documentation, and use the information to commence the production of service user plans. The home is able to demonstrate the capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home, by providing a good balance between its paperwork and practice. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 Staff respect service users’ rights to make decisions and strategies have been established in order to assist in the decision making process. Service users are supported to make choices and exercise control over their lives, with assistance if necessary. EVIDENCE: All of the care plans were not fully evaluated at this inspection, however some were examined as part of case tracking. Each resident’s file provides individual plans of care incorporating specialist needs and individualised procedures designed to meet the needs of the person. The documentation was being reviewed as dated and whenever possible the care plans are compiled with the service user and/or their representative, and are dated/signed. There were some anomalies identified which need to be examined. A review of one service users care management approach was being undertaken at the time of the inspection, due to specific practice issues having been raised. Another service user, with a sensory impairment has a staff alert system on his bedroom door for use at night. Ideally this person would be offered a ground floor room, but there is not a room currently available.
38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 11 The tone and volume of the call system is considered intrusive, and must be reviewed, and supported by a review of care management records, including care plan and risk assessment of the individuals needs/placement. In addition another service user is becoming increasingly threatening toward her peers and the situation may require intervention to protect other vulnerable adults within the home. Strategies must be in place to support this person and protect other service users. The home is currently working towards introducing life-story books as part of a person centred planning approach. Consideration needs to be given generally, as to how care plans can be reproduced in formats suitable for service users. As discussed at previous inspections, different systems may be required such as essential life style planning. With the help of speech and language therapists, staff have also assisted some service users to establish communication diaries. Since the last inspection the organisation has been actively using the services of `People First` advocacy group, who have visited the home and are in the process of producing a report for the service. It is not always possible for individual advocates to be appointed for service users but they may become involved in specific projects upon request. At the time of the inspection a random selection of risk assessments were reviewed. On examination of this documentation the home has an acceptable risk assessment process. Service users are risk assessed in a variety of activities and topics according to their individual abilities. A sample of generic risk assessments were reviewed and found to be acceptable, and these have been developed with regards to safe working practice topics. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15,16 and 17 Staff support service users to maintain family links and friendships inside and outside the home. The rights of individuals living at the home are respected and choices and preferences identified. EVIDENCE: 38 Dagger Lane operates an open visiting policy, and welcomes relatives and friends of service users at any reasonable time. The home provides two lounges/communal rooms and a dining area, plus service users rooms where visitors could have privacy, and for service users preferring a quiet area. About half of the service users have regular contact with family/relatives but for the remaining individuals the contact overall varies in length and frequency. Discussion took place with the acting manager about the need to support `historical` restrictions on service users receiving visitors and maintaining contact with relatives. This should be in the form of securing documentation as part of a multi agency agreement with the relevant named community nurse/social worker. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 13 The routines of daily life at 38 Dagger Lane continue to be flexible in terms of leisure and social activities, food and meal times and general routines of daily living. Service users likes and dislikes are identified and service user plans seen identified relevant limitations in relation to daily routines. Service users privacy and dignity, is respected with regards to personal care, entering toilets, bathrooms and bedrooms, and maintaining social contacts. Service users have access to a telephone, are spoken to using a preferred term of address, which is documented, and arrangements are in place to ensure personal clothing/laundry is returned to its owner. Personal mail is presented to service users unopened and the individual is assisted with the contents as needed. The occupants of the home have unrestricted access to the majority of areas. The arrangements for smoking, pets and alcohol are made clear to prospective service users and noted in the terms and conditions of residency. Service users at Dagger Lane are offered a choice of meals from a menu, which respects individual preferences. It has been previously recommended that the menu system be expanded to provide a pictorial menu guide in assisting service users with communication needs to make an informed choice. Work on this is ongoing. Each mealtime can offer an alternative, in addition to frequent drinks and snacks. Service users are served their meals, by support staff, and cultural, religious, and special diets can be accommodated as needed. The majority of staff have been provided with training in Basic Food Hygiene. Mealtimes are relaxed and unhurried for service users who generally eat in together in the dining room at the time. Nutritional needs of service users are routinely risk assessed. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 The health care needs of service users are met due to good care planning. The medication system at the home is well managed, promoting good health. However, some additional work needs to be done to comply with recent changes and good practice. EVIDENCE: There was evidence available to indicate that service users healthcare needs are being met. Various healthcare services continue to be utilised by staff for service users. The acting manager stated that generally services are accessed via community facilities rather than brought in to the home. Records available at this inspection offered details of accessing routine and specific health care facilities. Service users attend 3 monthly reviews with their respective consultant, and also visit their choice of GP or a home visit is requested. Equipment was available for the promotion of tissue viability. Evidence also included contact with Physiotherapy, Dentists, Opticians, Chiropody, etc. Information has been collated for easy reference and for identifying any shortfalls in provision.
38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 15 All of the service users have been assisted to attend a `well person` healthcare check. There was also information documented about the home utilising the services of the Speech/Language therapy department. Service users weight is routinely monitored. Procedures and practices within the home in relation to medicines and controlled drugs were satisfactory. Medication keys are held by the nurse in charge and handed over at staff change times. Staff signatures for the homes medication policy have been obtained as an acknowledgement of its content/existence, and signatures were available of qualified staff who administer medication to service users. The acting manager needs to ensure that this list is kept up to date and includes agency staff. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 16 Service users receiving PRN, (when required) medication are the subject of a care plan, demonstrating frequency and under what circumstances to be administered etc. A protocol for the administration of invasive medicines is included in relevant service users plans. None of the service users at Dagger Lane self medicate and due to the nature of their disability, it may not be possible to secure consent to medication being given. Due to the nature of the disabilities presented by this client group, the Manager has attempted to explore the issue of consent to medication being given. This has included relatives where possible. The issue of covert medication needs to be explored further with regard to one service user. This must be done as part of a multi agency agreement, documented appropriately and in line with good practice guidance issued by the Nursing and Midwifery Council. Evidence of medication reviews was seen on personal files. The home has reviewed the system for service users medications and has chosen to continue to adopt the `bottle` system rather than a monitored dosage system. Weekly medication stock checks are undertaken and records are maintained for this. Medication administration sheets are handwritten by qualified staff. Printed sheets should be used to reduce the risk of error, either in recording or administration. These may be utilised through the contract with the supplier or by the home using a personal computer, which will enable the staff to amend records on receipt of the supplies each month. Copies of prescription are available to support changes. The acting manager is advised that from April 1st 2005 a new NHS contract for community pharmacists was introduced. Effective immediately, care homes (nursing) are prevented by law from returning waste medicines to a community pharmacist. Arrangements must be made with a licensed waste management company, as required for other clinical waste. Therefore community pharmacists cannot accept medication waste from care homes (nursing only), unless their pharmacy holds a Waste Management Licence. This must be explored with the community pharmacist and records be maintained of the system in place, for the purpose of inspection. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 There is a clear complaints procedure for service users and relatives, thereby ensuring individuals views and concerns are listened to and acted upon. Arrangements for protecting service users through working practice, staff awareness and knowledge is not as good as it should be and requires review. EVIDENCE: 38 Dagger Lane operates Lonsdale Midlands Ltd complaints procedure and records will be kept of any complaint or issues raised. No formal complaints had been received at the time of inspection. The complaint procedure contains details of the Commission for Social Care Inspection, and the procedure is available to service users and representatives, in appropriate formats. The company’s complaints procedure details how to make a complaint, to whom and the timescales involved. The organisation has an Adult Protection policy that has been referenced to the Department of Health guidance ‘No Secrets`. This policy has been brought to the attention of all staff, previously through a staff meeting and briefing session. Training in Adult Protection issues has been provided for the majority of staff, and certificated evidence was available in the sample of staff files examined. The home has copies of the Department of Health guidance ‘No Secrets`, and the local Sandwell Vulnerable Adults Procedure. Recent practice issues have highlighted the need for staff to be made aware of the company policies and procedures which cover the topics of protecting vulnerable adults and `whistleblowing`. The organisation is the process of arranging this, with additional guidance for qualified staff in reporting notifiable incidents under Regulation 37 of the Care Homes Regulations 2001. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) nil No standards from this section were assessed as part of this inspection EVIDENCE: The storage bins for household and clinical waste should be stored for safety reasons, in a designated area and screened from view. The side gates to the premises do not offer sufficient privacy to the occupants of the home. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 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 and 34 There is a thorough recruitment procedure in place, which ensures the protection of service users. Staff have the qualities to meet service users needs. EVIDENCE: The home employs 10 support staff, 3 of who are qualified to NVQ II or above. There are a further 6 staff who are currently undergoing level 3 training. Mandatory and specialist training is also on-going. The home operates the organisations recruitment and selection procedure. A sample of staff files was viewed as part of this inspection. Information contained in staff files included application forms, (and statement of health/convictions) copies of two written references, job description and contract, and proof of I.D. Staff files seen indicated that a Criminal Records Bureau check had been conducted or had been received for staff, and evidence in the form of an `enhanced` check is available for all staff employed at the time of this inspection. Staff files are well organised and presented. The management has worked well to secure this information and has made good progress.
38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 20 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) nil No standards from this section were assessed as part of this inspection EVIDENCE: Not applicable 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x x Standard No 22 23
ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 x x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x 2 3 3 Standard No 31 32 33 34 35 36 Score x 2 x 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
38 Dagger Lane Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 22 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 2, 6 Regulation 14, 15 Requirement Strategies/documentation must be in place to support all care related issues. (To include those identified in the second section of the contents of this report, and as discussed at the time of inspection). The home should implement a system of Person Centred Planning or similar, such as Essential Lifestyle Planning. Any visiting restrictions or arrangements must be documented appropriately and supported through a multiagency agreement The manager must ensure that a) the homes chosen community pharmacist holds a Waste Management Licence for the disposal of unused medications or alternative arrangements are made with a Waste Management company. b) Medication administration records should be printed sheets to reduce the risk of error, either in recording or administration. c) The issue of covert medication needs to be explored further with regard to one service user. Timescale for action 30/9/05 2. 6 15 31/12/05 3. 15 13 30/9/05 4. 20,42 13 a) 31/8/05 b)30/10/05 c) 30/9/05 d) 31/8/05 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 23 5. 23 13 d) The manager needs to ensure that the signatures and list of all qualified and agency staff involved in the administration of medicines, is kept up to date. All staff must be routinely made aware of the company policies and procedures which cover the topics of protecting vulnerable adults and `whistleblowing`. 30/9/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 24,18 30,42 32 41 Good Practice Recommendations The side gates to the premises do not offer sufficient privacy to the occupants of the home, and should be enhanced with screening or replaced. The storage bins for household and clinical waste should be stored for safety reasons, in a designated area and screened from view. The home continues to work toward meeting Sector Skills Workforce targets of 50 of care staff having achieved an NVQ level 2 or above by 31/12/05. The home should consider obtaining a personal computer, which will enable the staff to produce forms and doucments and for example, amend medication records on receipt of the supplies each month. 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Mucklow Office Park West Point Mucklow Office Park, Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 38 Dagger Lane E55 S4770 38 Dagger Lane V228539 Announced 29-6-05 Stage 4.doc Version 1.40 Page 25 - 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!
