Inspection on 09/05/05 for 46 Sedgley Road

This inspection was carried out on 9th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 65 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

46 Sedgley Road 17/07/07

46 Sedgley Road 19/07/06

46 Sedgley Road 19/10/05

46 Sedgley Road 09/11/04

46 Sedgley Road 05/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 46 Sedgley Road Swan Village Care Services Ltd. Woodsetton Dudley. DY1 4NG Lead Inspector Lesley Webb Unannounced 9 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 46 Sedgley Road Address Woodsetton Dudley West Midlands. DY1 4NG 01902 662991 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Swan Village Care Services Ltd. None Care Home 5 Category(ies) of Learning Disability (5) registration, with number of places 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9th November 2004 Brief Description of the Service: 46 Sedgley Road is a privately owned care home, which has been registered to provide care for a maximum of five adults who have learning disabilities. The registered proprietors, Swan Village Care Services Limited, have five other care homes in the West Midlands. The home is situated in a residential area of Sedgley and has a regular public transport system that enables easy access to Dudley and Wolverhampton town centres and places of local interest such as Dudley Zoo, the Black Country Museum and the local nature reserve. The home has its own transport. There are car-parking facilities at the rear of the premises. Sedgley Road comprises two floors; on the ground floor are a lounge, kitchen/dining area and a single bedroom with adjacent shower room. The first floor has four single bedrooms and bathroom. At present, service users who wish to smoke may do so in the rear porch, or with the permission of other service users, in the lounge. The home does not provide any lift facilities and therefore is not suitable for service users with physical disabilities. Visitors are welcomed at any reasonable time. They are requested to sign the visitors book in the hall, on their arrival and departure. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at the home at 12.30pm when three service users were out at day care and the remaining two people who live at the home were out in the community. The Inspector stayed at the home until 6.30pm during which time records were looked at, staff interviewed, the building toured and the Acting Manager spoken to. Once service users came back to the home the inspector spent time talking to them and observing practices and relationships between service users and staff before giving feedback about the inspection to management. The Registered Manager retired in August 2004 with a senior care assistant, Mrs Eunice Harrison, covering this position before a new manager was appointed at the beginning of April 2005. However the Commission for Social Care Inspection was notified that the Acting Manager had resigned at the end of April with Mrs Harrison agreeing to cover the manager’s position until a new manager can be recruited. By the end of the visit the inspector was satisfied that in general the levels of care provided were adequate but had concerns that staffing levels could impact on service provision due to the Acting Manager not undertaking hours supernumerary to care and staffing levels not being maintained to agreed levels. The inspector informed everyone that these issues must be addressed immediately and that an extra monitoring visit would be undertaken to ensure the appropriate staffing levels were being maintained with further action a possibility if non-compliance is found. What the service does well: What has improved since the last inspection? 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 6 At the last inspection lots of medication issues were found, with most of these now being addressed reducing the risk to service users of misadministration. In addition to this staff records have improved, as previously these did not met legal requirements and did not ensure service users were protected. 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. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed at this inspection. EVIDENCE: 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9. Careplans must be developed to contain aims and goals in order that staff have the information they need to satisfactorily meet service users needs. There is little evidence that the homes takes responsibility to support service users with communication difficulties to become involved in decision making processes. EVIDENCE: Individual plans of care are available but none sampled contained assessed needs and personal goals. This was confirmed as normal practice when none of the staff that the inspector spoke to could give any examples of aims and goals contained within care plans. The inspector noted that one service users plan stated that they bath infrequently and that staff have been recording when this occurred. This, the inspector explained to staff, would be an area that should have recorded aims/goals that are reviewed on a regular basis. In addition to this no service user could confirm if they had a care plan or were involved in its compilation with one individual stating, “ I didn’t think we were allowed to look at our records”. Discussion with staff suggested that some needs were being addressed even though there is a lack of clear plans and guidance. This 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 10 approach is dependent on staff memory and good verbal communication systems. Service users are at risk of not having their care needs met if these informal systems break down. The inspector was also concerned that one service user spoken to thought that they did not have an allocated key worker stating, “ I used to but she left”. When the inspector looked in to this she was shown documents that demonstrated everyone living at the home is given a key worker, but no evidence that the service users had been made aware. The inspector was also concerned that some staff are unsure if care plans were being reviewed and who should be involved in this process. Both service users that the inspector interviewed gave examples of choices they are allowed to make including visiting relatives, activities, and household tasks and house rules such as not going in other peoples rooms without their permission. When the inspector asked staff if service users are consulted on and make decisions about their life in the home all staff said, “those who can talk”. It was the general consensus that communication makes it difficult for some services users views to be known. The inspector was therefore disappointed that no service user meetings had occurred since October 2004 and no one at the home had undertaken communication training. When the inspector asked if anyone used advocacy services to support them in decision making, all staff stated that this had never occurred with one person adding, “ I don’t think anyone has suggested it”. The inspector could find very little evidence that service users are supported to make decisions about their lives, and no evidence that the home take a proactive stance in this area. No progress has been made to ensure all areas of risk associated with individual service users are clearly documented including falls and personal safety within the home despite this being identified in a previous inspection. All files contained risk assessments, however none complemented the needs of individuals as detailed in their plans of care and assessments. For example a risk assessment had been completed which stated that an individual was at high risk from unwanted pregnancies and sexually transmitted diseases but then went on to state that the assessment would not require reviewing for another six months. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16 and 17. Choice is limited for service users to lead fulfilling lives outside of the home due to low staffing ratios. Meals in the home are poor with little evidence that service users are offered either quality meals or choice. EVIDENCE: Activities are limited due to the current staffing levels (see Standard 33). Records held by the home do not demonstrate that service users participate in a range of in-house and external activities with only an average of four activities recorded as taking place over a three month period for each service user. One service user that the inspector spoke to stated that they go out almost everyday but that they do not need staff to escort them. For the three service users who require staff assistance very little evidence could be found that they lead full and varied lives, with staff confirming attendance at daycentres as the only regular activity outside of the home. No progress has been made to devise and implement daily activity planners for each person, to include structured and spontaneous activities at weekends/holiday times, and introduce a documented evaluation process for all activities taking note of refusals, as identified in a previous inspection. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 12 All the service users that the inspector spoke to confirmed that family contact is important to them, giving examples of visits undertaken and contact via the telephone. In addition to this one service user told the inspector about a relationship they had and how the staff had helped seek advice from outside professionals to support her. Little evidence could be found that demonstrated staff awareness of service users rights and responsibilities. For example the service users that the inspector spoke to all stated that they had not been offered a key to their home. When asking staff why this was the case, some were unsure and another stated, “keys might get lost”. The inspector instructed that assessments must be completed that demonstrated each persons abilities to use this facility along with written confirmation of their choice to decline, if they so wish. The inspector also instructed that assessments must be completed that demonstrate the same for service users rights to a key to their bedroom. At dinner the inspector noticed that service users were not offered a choice of meals. Staff confirmed that menus are not planned in advance and choices are not offered as part of the planning process, but that if a service user indicates that they do not want the meal that is being prepared they will be offered an alternative if possible. None of the records maintained relating to service users meals demonstrated that they are given healthy, well-balanced meals, with over half the meals consisting of chips or sandwiches. Staff stated that it is difficult to offer a choice of well-balanced meals for five people with a food budget of £70. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20. Service users could potentially be at risk as their personal and healthcare needs are not documented in full. EVIDENCE: The inspector could not be satisfied that service users preferences about how they are assisted with personal support and care are maintained as care plans do not give enough detail (see Standard 6). One member of staff commented that, “two service users can tell you what they want, but the others can’t, you have to look for signs”. When the inspector asked for examples of these signs the staff member was unable to give any. Again although staff confirmed service users health needs are met records relating to these were found to be incomplete. For example Initial Health Assessments have not been completed in full and some service users files did not contain evidence of annual health checks with chiropodists, hearing and an optician. Medication procedures have improved since the last inspection with many previous requirements now addressed. Further requirements relating to the recording and storing of Controlled Drugs must be addressed to meet National Minimum Standards. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home has a satisfactory complaints system however no evidence that service users views are listened to or acted upon could be found. Further guidance is required for staff to ensure they understand in full adult abuse and the protection of vulnerable adults. EVIDENCE: When the inspector asked service users who they would talk to if they were unhappy one stated, “probably one of the staff” and another named one individual working at the home. When asked if staff listen to them if they are unhappy both replied, “Not always, they are busy”. But one then went on to state, “ sometimes I say I want to leave but that’s because I’m in a mood, its nice here, better than where I lived before, the staff are better, they talk to you better”. Staff confirmed that they try their best to listen when service users are unhappy and would report to seniors any concerns. No complaints have been lodged at the home since 2002 however the inspector could not ascertain if this was due to no one having issues or whether service users and their representatives are aware of their rights to complain, as no evidence could be found that service users are given guidance in this area. When asked how they ensure service users are protected from abuse staff gave examples such as looking for signs or changes in mood. No one discussed listening to service users, reporting to senior staff or gave examples of the differing forms of abuse. Staff also confirmed that they had not undertaken training in this area. The inspector recommended that the home obtain copies of Adult Protection Procedures from the various placing authorities as additional guidance for staff. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 28 and 30. The standard of decoration and furnishings in parts of the home is poor with little evidence of improvement through maintenance or future planning. The home does not, therefore, present a homely and comfortable environment as it could for service users. EVIDENCE: On the day of inspection the premises were clean and free from offensive odours. It was noted by the inspector that some repairs had been made to the premises as identified in previous inspections but that a high proportion still remain outstanding. In addition to these the inspector found further areas requiring attention due to further deterioration since the last inspection resulting in some areas feeling worn. * The suite in the lounge must be replaced due to many of the springs inside it being broken and the covering being worn and torn. In addition to this the inspector found that the suite is very low to the ground and observed service users having difficulty using this facility. * The walls in the lounge require painting due to being stained. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 16 * One service user can be incontinent and therefore a sluicing facility must be provided in the laundry. * The dining table must be replaced due to the legs being broken and insecure causing potential risk to users. At least five dining chairs must be available for use in order that service users can sit together when eating if they so wish. * The upstairs bathroom must be assessed by a qualified person for the appropriate aids and adaptations due to staff recognising that hand rails may assist a service user with additional needs. Also the flooring in this room must be sealed around the edges to ensure fluids do not seep underneath. * Garden furniture must be provided that is appropriate to the needs of the people living at the home. * The garden at the rear at the property requires attention, with weeds removing and lawn attending to. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 17 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) 33,34, 35 and 36. The decrease in staffing levels has impacted upon all aspects of care, this in turn results in service users receiving an inconsistant service that thas the potential to place them at risk. Staff need further training and support in order to meet the assessed needs of the people living at the home. EVIDENCE: When previously inspected concerns had been raised regarding staffing levels and the needs of service users and the home had been instructed to forward assessment levels of individuals to CSCI for consideration, however this still remains outstanding. The inspector was further concerned to find that since the beginning of April 2005 there has been a further reduction of staffing hours; with now only two staff on duty at weekends as opposed to three. In addition to this the Acting Manager has not been working supernumerary to care. The inspector found an abundance of evidence that these staffing levels are impacting on care provision, with particular attention to lack of activities, personal support and maintaining records required by regulation. The inspector instructed that these practices must cease immediately and that a further follow up visit to the home would take place to monitor compliance. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 18 No progress has been made to expand staff rotas to include service users dependency levels and occupancy levels and to demonstrate total number of care hours provided, to forward a copy of the training agreement recently implemented with all members of staff to CSCI and to provide documentary evidence of five days paid training for each staff member as identified in previous inspections. Individual staff training and development plans have been put into place but need further development in order that they detail developmental needs that may not require formal training. The inspector sampled two staff training files and found one contained certificates for manual handling (2003), fire (2001) and Crisis Prevention Intervention (2004) and the other certificates for TOPPS induction (2004), Crisis Prevention Intervention (2004), fire (2004), infection control (2005) and food hygiene (2001). As well as staff confirming that they had not undertaken all mandatory training required,they also stated that they had not undertaken specific training to meet service users needs such as communication, diabetes and epilepsy. One member of staff also stated that she had completed NVQ level 2, however, no records were available to validate this. Improvement has been made in relation to the retention of staff recruitment records with all those sampled containing documentation required by legislation. Although the inspector was shown minutes of a meeting where service users were informed they would be involved in the recruitment of a new manager, no service users confirmed that this had occurred. All staff that the inspector spoke to stated that they had either received one or two supervision sessions or none at all. In addition to this all staff stated that they had never received an annual appraisal. It was therefore disappointing to find that staff meetings have not been occurring frequently, with three taking place last year. The acting manager stated that one had occurred this year, however records were not available to verify this. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 42. Since August 2004 there has been no consistant leadership, guidance and direction for staff to ensure service users receive consistent quality care. this results in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: There is no registered manager and this has been the case since August 2004. There have been two acting managers in this time, the current one has been post for three weeks but has no intention of submitting an application to be registered. The Commission for Social Care Inspection is liaising with the registered providers to ensure they proactively recruit a new manager and submit an application to register. The number of outstanding requirements, inspection of records and discussions with staff confirm that the lack of 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 20 consistent management in the home is having a detrimental effect on the running of the home. When the inspector checked the water temperatures from various outlets it was found that they ranged from 22C to 52C. The inspector raised concerns regarding these temperature ranges and reinforced that the home must undertake a documented risk assessment of the excessive temperatures of hot water outlets, and forward proposals for a resolution to CSCI as identified in a previous inspection. No progress has been made on several requirements identified in previous inspections - to ensure all staff receive as a minimum 2 fire safety training sessions and participate in two fires safety drills in any 12 month period, to provide a strap on thermometer for the boiler to ensure hot water storage is maintained at 60c/50c on return, to progress training dates for moving and handling, food hygiene, health and safety and fire, to ensure identified recommendations required from the legionella risk assessment are actioned and a chlorination certificate is forwarded to CSCI, to provide documentary evidence that risk assessment training has been arranged for all staff, to ensure that a up to date financial and business plan is available for inspection and to make arrangements for the last audited accounts for the home to be made available to CSCI. The home has still to implement a quality assurance system. The inspector was shown such a system but found that this had only been completed in part and did not evidence that the views of service users, their families and other interested parties had been sought. 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 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 x x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 2 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x 2 x 2 Standard No 11 12 13 14 15 16 17 x 2 1 x 3 2 1 Standard No 31 32 33 34 35 36 Score x x 1 2 2 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 46 Sedgley Road Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 1 x 1 x x 1 x v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement All service users must have comprehensive care plans that cover all aspects of personal, social support and healthcare needs as set out in Standard 2.3 of the National Minimum Standards and must also detail aims ands goals stating how these needs will be met The home must be able to demonstrate that service users are involved in the compilation of their plans of care Service users must be made aware of who their keyworker is All care plans must be reviewed at least every six months, with the involvement of the service user All staff must undertake communication training specific to meeting the needs of service users The home must ensure service users have access to advocacy services Service user meetings must be reinstigated, occur on a regular basis with records maintained The home must be able to demonstrate that issues/subjects Timescale for action 30/09/05 2. YA6 15 30/09/05 3. 4. YA6 YA6 15 15 30/09/05 30/09/05 5. YA7 12(2) 30/09/05 6. 7. 8. YA7 YA7 YA7 12(2) 12(2) 12(2) 30/09/05 30/09/05 30/09/05 Page 23 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 9. YA8 12(2) 10. YA9 13(4) 11. YA12 13(1) 12. YA14 12(1) 13. YA13 16(2) 14. YA16 12(4) 15. YA16 12(4) raised in service user meetings are actioned The home must demonstrate that service users are given the opportunity to be involved in recruitment and selection of staff The home must ensure that all areas of risk associated with individual service users are clearly documented, including falls and personal safety within the home(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) The home must be able to demonstrate that it is proactive in exploring with all service users opportunities for further education and training, taking into consideration their abilities (REQUIRMENT ORIGINALLY MADE NOVEMBER 2004) The home must devise and implement daily activity planners for each person, to include structured and spontaneous activities at weekends/holiday times, and introduce a documented evaluation process for all activities, taking note of refusals(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) Staffing levels must be in place that allow for service users to participate in activities outside of the home at weekends All service users must be offered a key to the front door of the building and to their bedroom and written documentation maintained where this has been declined. Risk assessments must be completed for those service users not offered these choices demonstrating why this decision has been made The home must demonstrate 30/09/05 01/06/05 01/06/05 01/06/05 30/09/05 30/09/05 01/06/06 Page 24 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 16. YA17 16(2) 17. 18. YA17 YA17 16(2) 16(2) 19. YA18 12(1) 20. 21. YA19 YA19 12(1) 12(1) 22. YA20 13(2) 23. YA20 13(2) 24. YA20 13(2) 25. YA22 22(1) that consultations are held with service users to obtain their views and preferences relating to refurbishment, redecoration and provision of new furnishings(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) Service users must be actively supported to help plan, prepare and service meals according to their abilities All service users nutritional needs must be assessed Service users must be offered a choice of suitable menus, which are nutritious, varied, balanced and attractive, with records maintained The home must be able to demostrate that service users preferences about how the are guided, moved and supported are complied with, and reasons for not doing so are recorded Health Assessments must be completed in full All service users must be offered minimum annual health checks for vision, hearing, chiropody and optitions The home must obtain an up to date British National Formulary(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) Controlled drugs must be stored in a cupboard which complies with regulations issued by the Royal Pharmaceutical Society Receipt, administration and disposal of controlled drugs must be recorded in a controlled drugs register A record must be maintained of all issues raised and complaints, details of any investigation, action and outcome; and this 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 01/06/05 30/09/05 30/09/05 30/09/05 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 25 26. YA23 10(1) 27. YA24 16(1) 28. YA24 16(1) 29. YA24 16(1) 30. 31. 32. 33. YA24 YA24 YA24 YA24 16(1) 16(1) 16(1) 16(1) record checked at least three monthly All staff must undertake adult protection training, with certificates maintained at the home To compoet repairs and redecoration of the outside of the property(REQUIREMENT ORIGINALLY MADE NOVEMBER 2002) To extend the hand rails in the rear garden and obtain appropriate professional advice relating to the Disability Discrimination Act in relation to access to the building(REQUIREMENT ORIGINALLY MADE OCTOBER 2003) To redecorate the interior communal areas, corridors and stairs(REQUIREMENT ORIGINALLY MADE MAY 2004) The lounge suite must be replaced The lounge must be redecorated The dining table must be repaired or replaced and at least five dining chairs made availible The home must have a planned maintenance and renewal programme for the fabric and decoration of the premises, with records kept The home must replace the flooring in the ground floor toilet and renovate and redecorate the toilet and bathing facilities(REQUIRMENT ORIGINALLY MADE MAY 2004) The upstairs bathroom must be assessed by a qualified person for the appropriate aids and adaptations eg hand rais The flooring in the upstairs bathroom requires sealing 30/09/05 01/06/05 01/06/05 01/06/05 30/09/05 30/09/05 30/09/05 30/09/05 34. YA27 16(1) 01/06/05 35. YA27 16(1) 30/09/05 36. YA27 16(1) 30/09/05 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 26 around the edges 37. YA28 16(1) Garden furniture must be provided that is appropriate to the needs of the people living at the home The garden at requires the weeds removing and lawn attending to The home must provide a sluicing facility The home must forward proposals for increase of staffing levels to the CSCI with a documented risk assessment as an interim measure(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) The home must expand staff rotas to include service users dependency and occupancy levels and to demonstrate total number of care hours provided(REQUIRMENT ORIGINALLY MADE NOVEMBER 2004) The home must ensure that management hours are supernumary to care The home must ensure a minimum of three staff are on duty at weekends The home must forward a copy of the training agreement implemented with staff to the CSCI(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) The home must provide documentary evidence of five paid training days for each member of staff(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) All staff must undertake epilepsy and diabeties training Certificates must be maintained 01/06/05 38. 39. 40. YA28 YA30 YA33 16(1) 13(3) 18(1) 01/06/05 01/06/05 01/06/05 41. YA33 18(1) 01/06/05 42. 43. 44. YA33 YA33 YA35 18(1) 18(1) 18(1) 10/05/05 10/05/05 01/06/05 45. YA35 18(1) 01/06/05 46. 47. YA35 YA35 18(1) 18(1) 30/09/05 30/09/05 Page 27 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 48. YA35 18(1) 49. YA35 18(1) 50. 51. 52. YA36 YA36 YA37 18(2) 18(2) 9 53. YA39 24 54. YA39 24 55. YA39 24 56. YA39 24 57. YA42 13(3-6) at the home that demonstrate staff have undertaken a NVQ and equal opportunities training A training needs assessment must be carried out for the staff team as a whole, and an impact assessment of all staff development undertaken to identify the benefits for service users and to inform future planning The home must be able to demonstrate that staff use Learning Disability Award Framework accredited training All staff must receive at least six formal supervision sessions a year All staff must receive an annual appraisal The home must proactively recruit a new manager and forward an application to the CSCI(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) The home must develop and implement effective quality assurance and monitoring systems(REQUIREMENT ORIGINALLY MADE NOVEMBER 2002) Quality assurance systems must include the views of service users, their families and other interested parties There must be an annual development plan for the home, based on a systematic cycle of planning, action and review The home must ensure action is progressed within agreed timescales to implement requirements identified in CSCI inspection reports The home must provide a strap on thermometer for the boiler to ensure that hot water storage is 30/09/05 30/09/05 30/09/05 30/09/05 01/06/05 01/06/05 30/09/05 30/09/05 30/09/05 01/06/05 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 28 58. YA42 13(3-6) 59. 60. YA42 YA42 13(3-6) 13(3-6) 61. YA42 13(3-6) 62. YA42 13(3-6) 63. YA43 25 64. YA43 25 maintained at 60c/50c on return(REQUIREMENT ORIGINALLY MADE OCTOBER 2003) The home must ensure all staff have moving and handling, food hygiene, health and safety, first aid an fire safety training(REQUIREMENT ORIGINALLY MADE OCTOBER 2003) Records must be maintained at the home of all mandatory training undertaken by staff The home must ensure the identified recommendations required from the Legionella Risk assessment are actioned and a chlorination certificate is forwarded to the CSCI(REQUIREMENT ORIGINALLY MADE MAY 2004) The home must provide documentary evidence that staff have undertake risk assessment training The home must undertake a risk assessment of the excessive temperatures of hot water outlet at the hand wash basin in the kitchen, as an interim measure, and forward proposals for a resolution to the CSCI(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) The home must ensure that an up to date financial and business plan are availible at the home for inspection(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) The home must make arrangement for the last audited accounts for the home to be made available to the CSCI(REQUIREMENT ORIGINALLY MADE NOVEMBER 01/06/05 30/09/05 01/06/05 30/09/05 01/06/05 01/06/05 01/06/05 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 29 2004) 65. YA43 25 The home must ensure that a food budget is provided that ensures service users are given varied, nutritious and quality meals 30/09/05 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 YA22 YA8 YA35 YA39 Good Practice Recommendations To proactively encourage discussion and actions on issues raised by service users in order that they are confident that problems will be listened to That the minutes of service users meetings are expanded to record outcomes to topics raised That dates of training completed are added to the training matrix That an annual schedule of meetings be devised and displayed in order that they become a priority for everyone 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 46 Sedgley Road v224887 e55 s25037 46 sedgley road v224887 090505 stage 4.doc Version 1.30 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!