Inspection on 21/11/06 for 48 Cedar Road

This inspection was carried out on 21st 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 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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

48 Cedar Road 30/08/07

48 Cedar Road 20/10/05

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 48 Cedar Road Dudley West Midlands DY1 4HW Lead Inspector Mrs Cathy Moore Key Unannounced Inspection 21st November 2006 08:00 48 Cedar Road DS0000063797.V320620.R02.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 48 Cedar Road DS0000063797.V320620.R02.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. 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 48 Cedar Road Address Dudley West Midlands DY1 4HW 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) 01384 241877 TBA Mr S Ball Lucy Fallon Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Physical disability (9), Sensory of places impairment (9) 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20/10/05 Brief Description of the Service: 48 Cedar Road is registered to provide care and accommodation for a maximum of nine adults, between the ages of 18 and 65, with acquired brain injury. Service users are offered 24-hour personal care and support, including one waking/one sleeping in night staff. The aim of the home is to provide medium to long-term support to service users to assist them to develop an independent lifestyle, according to their individual abilities The home is a two-storey detached purpose built property situated in a residential area of Dudley, close to local shops, amenities and public transport. It has its own transport and off-road parking is available to visitors. It provides good access for people with limited mobility. The first floor can be accessed by a passenger lift. Communal facilities include lounge, kitchen with large dining area, activity room and private rear garden. Nine single-occupancy bedrooms are provided all are spacious, furnished to a high standard and have en-suite facilities. Service users have the option to use the bathroom, if they prefer, and additional toilets are situated close to communal areas. The home has an open visiting policy. The weekly fee rate for this home is £1,250. 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 08.00 and 16.30 hours. The inspection assessed all key National Minimum Standards for younger Adults. Two service users’ case files were looked at to include their assessment of need documents, care plans and daily records. Three service users, two relatives and three staff members were spoken to. Observations were made in the lounge and dining room area of daily routines and staff/ service user interactions. The premises were randomly assessed to include the kitchen/ dining room, lounge, activities room, laundry, two bedrooms (with the permission of the service users) toilets and the bathroom. Two staff files were assessed to include looking at recruitment processes and training. Medication systems were assessed along with quality assurance processes and maintenance records. The deputy manager was involved in the inspection process. What the service does well: 48 Cedar Rd is located in a residential area near to the centre of Dudley. It is accessible to town centre shops and facilities, main bus routes and local shops. The home was purpose built. It is new only registered in 2005. The building is of a very good standard. It is of a generous size and well appointed. It offers large, single bedrooms all have en-suite facilities which include; a walk in shower, toilet and hand wash basin. Communal space comprises of a large kitchen/ dining room, an attractive lounge, activities room, training kitchen and a quite room. The home is well maintained and provides good quality furniture and fittings, which are domestic in style. An overall score rating of excellent has been given for the general environment. The atmosphere of the home was found to be positive, warm, friendly and welcoming. Staff were seen to be friendly and caring. Positive interactions were observed between staff and service users. Comments from staff included the following; “ The atmosphere of the home is good and it’s a nice place to work in”. “ It is rewarding seeing service users improve”. The home has its own transport enabling service users to go out and about on a regular basis. The home encourages service users to maintain contact with family and friends. Service users, which included the following, made positive comments about the home; “ The staff are nice”. “The home is very nice”. “ I like my bedroom”. 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 6 The home belongs to a larger organisation providing support and guidance. 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. 48 Cedar Road DS0000063797.V320620.R02.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 48 Cedar Road DS0000063797.V320620.R02.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): 3,5 Quality in this outcome area is Adequate This judgement has been made using available evidence including a visit to this service. Prospective service users cannot be fully assured at the present time that the home will be able to meet their complex specialist needs. Service users are not being provided with a written contract or statement of terms and conditions which contain all of the required information. EVIDENCE: Two service user files were assessed. It is positive that there was evidence available to demonstrate that a complex assessment of need had taken place regarding both of these service users. However, by speaking to staff and others and viewing documentation it was evident that only 2 staff have received training to equip them with the complex needs of the people in their care. Further, there has been some delays in obtaining specialist input for at least one service user. A person described the home as; “ Being able to meet the basic care needs of the service users, but not always the specialist needs”. The home advertises itself as being expert in caring for people with Acquired brain injuries but is not always able to evidence this which was summed up by one person as; “ Not doing fully what it says on the can”. 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 9 There was no evidence on files to show that that service users are given written assurance that the home can meet their needs as should be done. Although a terms and conditions agreement was on file these did not all contain the information required for example; the weekly fee rate for each person. 48 Cedar Road DS0000063797.V320620.R02.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. Service users needs are written in a personal care plan. Plenty of evidence was available to demonstrate that service users are able to make decisions about their lives. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: Care plans seen were of a good standard in that they held a lot of personal information and included key areas of care. There was evidence to show that care plans are being updated regularly, which is positive. One detail missing on care plans viewed was evidence that care plans had been produced in 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 11 consultation with the service user or where consented by the service user their chosen representative. It was clear from observations and speaking to service users that they are very much encouraged to make decisions about their daily lives and future plans. For example; their morning rising times. One service user said; “ They let me make my own mind up what I do. Sometimes I like to go out but only when I want to, but that’s o.k.” Risk assessments were seen on the files viewed. These covered a range of subject areas examples being; mobility, getting lost and activities outside of the home. Service users are encouraged within the home to maintain or enhance impendence which may hold an element of risk this confirmed by one resident who said; “ I can make my own drinks in the kitchen if I want to”. 48 Cedar Road DS0000063797.V320620.R02.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): 11,12,13,14,15,16,17. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are able to take part in a range of appropriate activities including accessing community facilities and leisure pastimes. The home encourages service users to maintain contact with family and friends. Service users rights are respected. Service users are offered a varied diet in pleasant surroundings. EVIDENCE: To enhance development and skill service users are set individual appropriate goals which include various in-house and external based tasks. These goals are then recorded when attempted and achieved and are meant to be reviewed on a regular basis. However, for what ever reason recording and review of these individual goals of late have been somewhat inconsistent which could be 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 13 detrimental to service users in terms of their overall progress and development. Service users are encouraged and enabled to take part in a range of activities. One of the service users enjoys doing voluntary work. Others enjoy going out to the library and other places within the community. During the inspection a number of services users’ went shopping in Dudley town which is close by. One service user said; “ I enjoy playing golf once a month and like to go to the library”. It is a great advantage to all service users that the home has its own transport to enable them to go out within the community and to visit places of interest. It was extremely positive that the home has good activity provision within. It has an activities room that has a range of provisions an example being; a snooker table. A number of service users during the inspection were observed enjoying the facilities in the activities room. One service user during the afternoon was seen making a cake with the supervision of a staff member from the expression on her face it was clear that she really enjoyed doing this. Five service users went on holiday this year to Skegness, which was reported to have been a success. Service users are very much encouraged to maintain contact with family and friends within and outside of the home. Records showed that most service users receive regular visitors, a number also go and visit their families. One service user was spending time out of the home with his family at the time the inspection took place and one relative said; “ She comes home every few weeks for a number of days”. The rights of service users are upheld wherever possible for example their right to vote is enabled. Advocacy information was available and records showed that a number of service users have been offered this service but have declined the offer. Service users rights to privacy are also upheld one prime example of this being; that they are all offered a single bedroom. One service user said; “ I enjoy spending time on my own sometimes just watching the television and I can do that”. The home has a weekly menu which the service users help to produce. A range of foods is offered which include fresh fruit and vegetables. Special diet information for conditions such as diabetes is available within the home. It was pleasing to see that staff ask service users on admission their diet and drink likes and dislikes which are recorded on their file. Food intake records are maintained to monitor adequate food and nutrition intake. Service users who wish are able to help with food preparation and cooking. The home has a very pleasant kitchen/ dining room where service users can take their meals. One service user was seen to be having her lunch in the lounge, as that is where she wanted to eat at that time. One service user said; “ The food is ok if I do not like something I ask for something else”. Staff were heard asking service users at lunchtime what they would like to eat and offering drinks at different times. 48 Cedar Road DS0000063797.V320620.R02.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 This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way that they prefer. Further developments are needed to ensure that service users physical and emotional health care needs can be met. Medication safety needs some ‘fine tuning’. EVIDENCE: Each service user is provided with their own personal care facilities (en-suite with hand wash basin and shower) to enhance privacy and dignity. Service users accommodated at the present time are able to attend to their own personal care needs with supervision and prompting. Care plans give a lot of detail about how the personal care needs of each service user should be met- all encourage independence. For example; one care plan read;” I can dress and undress myself but I may need prompting”. One service user said;” They let me do what I can”. One relative said; Her personal care is being met”. 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 15 As previously stated the home when assessing prospective service users must undertake research to ensure that specialist healthcare services can be accessed without undue delay before they offer that person a place especially if the prospective service user lives out of the area. It was determined that one service user has had to wait considerable time to see a specialist. Similarly, the home assessed a while back that due to specific needs of service users it needs the frequent input from a neuro psychologist yet to date although developments are being made the home has not secured this service. It was noted from records when a recent event happened the home was very quick to secure appropriate medical input. A service user complained of pain in the leg and was admitted to hospital quickly where it was identified that she had a blood clot. There was evidence that service users are weighed regularly to identify weight loss or gain. Medications are stored safely in a suitable cupboard. There was evidence of recording of the receipt and return of medications. Medication records were assessed it was positive that there were no staff initial gaps. One concern was identified in that one staff member who has not received formal medication training has been given responsibility for medications and administration which should not happen. Also a limited number of medication records were seen to be hand written yet there was no evidence to demonstrate that two staff had verified that the information transferred to the records were correct as should happen to prevent error. 48 Cedar Road DS0000063797.V320620.R02.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 Good This judgement has been made using available evidence including a visit to this service. Complaints processes are in place within the home. Further developments are needed to enhance protection processes within the home. EVIDENCE: The Commission about this home has received no complaints. The home has received two complaints since the last inspection, which have been recorded in the complaints book, which is positive. Records have been made how these complaints have been addressed which is also positive. However, there was no evidence that responses to complainants of outcomes of investigations are being given to them in written form or that they are encouraged to write to the home to confirm their satisfaction or otherwise of how their complaint has been dealt with. The home does have a written complaints procedure. It was pleasing that one service user was able to explain how they would address a complaint as follows; “ If I had a complaint which I have not I would speak to the person concerned, if I was not happy with that then I would go to the manager. I have not seen a written process though”. One service user displays frequent inappropriate sometimes-sexual behaviours towards staff. There has also been a number of episodes physical aggression towards other service users. Risk assessments are in place and referral has 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 17 been made to appropriate agencies and services. These behaviours must continue to be monitored and managed to prevent harm to service users. An outstanding requirement remains for staff that have not already to receive abuse awareness training. Two service users’ money held in safe keeping by the home were checked against balances and records and were found to be satisfactory. 48 Cedar Road DS0000063797.V320620.R02.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): 24,25,27,28,30. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users live in an environment which is new, clean, bright, homely, comfortable and provides ample private and communal space. EVIDENCE: The home’s premises are of an excellent standard. The home was purpose built and opened only in 2005. The homes atmosphere is warm, welcoming and friendly. Furniture and fittings throughout the home are of a good standard and are domestic in style. Hallways and landings are wide and spacious. The home has a passenger lift to enable service users who have poor mobility safe access to the first floor. An assisted bathroom is available on the ground floor for service users who need 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 19 this assistance. Moving and handling equipment is available throughout the home. Disabled access toilets are available on each floor. The home provides a variety of communal rooms. It has a large attractive kitchen/ dining room, an attractive generous sized lounge, a small lounge, activities room and a training kitchen. All bedrooms are of a very good size. They are all single occupancy with ensuite facilities provided. The home was seen to be clean. There were no offensive odours. The laundry is well equipped for the size of the home. Service users are allocated different clothes washing days this to enhance dignity and prevent any possible transmission of infection. One relative said; “The premises are excellent- cannot be faulted”. One service user said; “ I really like the home- especially my bedroom”. The only concern identified was the covering wet leaves on the roadway leading to the homes drive which could be a potential slipping hazard. The deputy manager said; “ We are dealing with that at the moment. It is the councils responsibility”. 48 Cedar Road DS0000063797.V320620.R02.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): 32,33,34,35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users at present are supported by staff in adequate numbers but not supported by a competent and qualified staff team. Recruitment practices need some ‘fine tuning’. EVIDENCE: Concern was raised during the inspection due to the fact that only two of the staff group have received recognised training in the area of brain injury. The home states in its literature that ;” We aim to work well with people who have a brain injury” and “ All of our staff are trained to look after you and understand how things should be done properly”. Yet how this is done when the majority of staff have not received the appropriate training or experience is debatable. A concern letter was issued for this to be addressed. It was identified that only one care staff member at the present time has an NVQ award. The deputy did confirm however, that a number of staff at the present 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 21 time are working towards NVQ awards. The NVQ status of the home will be focussed on again during the next inspection. There have been staffing problems in that over the year there has been a significant turnover consequently agency staff were used at times. However, staffing numbers now seem to be adequate. Three staff are provided during waking hours plus a manager most weekdays. One waking and one sleeping in staff members are provided at night. The deputy confirmed that these staffing levels are adequate at this time especially as only 5 service users are accommodated. Comments were made about the staff which included;” I’ve got no problems with the staff they are good. I don’t like it when they are new though don’t know what to do”. “The staff appear to be kind”. Two staff files were sampled to assess recruitment practices. These were mostly in order; there were two written references and an application form available, with the exception of evidence of a clear CRB/POVA list check for one. The top of this CRB was available showing the staff members name but it did not state whether or not a POVA list check had been carried out and if the check had been satisfactory. The deputy manager indicated that other CRB checks were similar to this one. It is clear that the home is trying to address gaps in staff training needs, which especially applies to very new staff. However, development is needed in this area. Each staff member needs to have a training plan on file to state what training they have done and confirmed dates of planned training where there are gaps together with evidence of paid training days. 48 Cedar Road DS0000063797.V320620.R02.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. This judgement has been made using available evidence including a visit to this service. The Commission as a fit person to be in charge of the home has approved the manager. Quality monitoring process and some health and safety aspects need further development to ensure that the home is run totally in the best interests of the service users and is completely safe. EVIDENCE: The Commission as a fit person to run and be in charge of the home has approved the manager. She has achieved the Registered Managers Award, 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 23 which is very positive. Unfortunatley, the manager was on leave at the time of the inspection so was not able to partake in it. It is pleasing that some quality assurance processes are in operation within the home examples being; service user satisfaction questionnaires. However, a self audit system against the whole functioning of the home and the National Minimum Standards for Younger Adults was not available as it should be. Generally health and safety processes within the home are adequate. A random audit of maintenance records was undertaken which included; hoisting and fire equipment were found to be in order. When looking at bedrooms it was noted that wardrobes are not secured as they should be to prevent them falling on service users if they were pulled. It was noted from records that water temperatures in the kitchen and laundry well exceeded 43oC placing service users at possible risk. Unfortunately there was no evidence or risk reduction processes in place as there should be. It was identified that a number of staff require first aid and fire drill training. action must be taken to address this to enhance safety within the home. 48 Cedar Road DS0000063797.V320620.R02.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 x 2 x 3 2 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 4 26 x 27 4 28 4 29 x 30 3 STAFFING Standard No Score 31 x 32 1 33 3 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 3 x LIFESTYLES Standard No Score 11 2 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 2 x x 3 x 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 25 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 YA3 Regulation 14 Requirement The registered person must ensure written confirmation is provided to a prospective service user as to whether the home is able to meet her/his assessed needs. Timescale of 12/12/05 not met. The registered persons must ensure that the full needs of each prospective service user can be met before they are offered a placement at the home this to include if needed; access to specialist resources and that staff are trained and fully competent in meeting all identified needs. This was discussed with the deputy manager during the inspection. Timescale for action 21/12/06 2 YA3 14 21/11/06 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 26 3 YA5 5 The registered person must ensure each service user has a contract/statement of terms and conditions which includes all elements detailed in NMS 5.2. Timescale of 13/01/06 not met. The registered persons must be able to evidence (wherever practicable) that service users or if appropriate their representative, have been consulted about their care plan and where ever possible are involved in its production and review. 05/01/07 4 YA6 15(1) 15(1)( c) 20/12/06 5 YA11 12(1)(b) 6 YA19 12(1)(a) 13(1)(b) 7 YA20 13(2) The registered persons must ensure and be able to demonstrate that each service users goals are being worked towards consistently and that this can be evidence at all times. The registered persons must be able to demonstrate that all healthcare / specialist care can be accessed to meet the needs of each resident. This to include confirmation that the Neuro psychologist has been secured. The registered persons must ensure that no staff member has responsibility for medications – which includes the administration of unless they have received appropriate formal training. This was emphasised to the deputy manager during the inspection. 05/12/06 05/01/07 21/11/06 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 27 8 YA20 13(2) The registered persons must ensure that where medication records are handwritten that two staff sign to verify that information transferred fro packs/ bottles/ packets is correct. 01/12/06 9 YA20 13(2) 10 YA23 13(6) 18(1)(a) The registered persons must ask their providing pharmacist to ensure that the top of the medication record page is fully completed to include the doctors name and any allergies or ‘ non known’ where this applies. The registered person must ensure that all staff are trained in adult protection. Timescale of 10/02/06 not fully met. 21/12/06 20/01/07 11 YA32 18(1)(a) The registered person must secure training for all staff who work at 48 Cedar Rd to equip them with the skills and knowledge to look after people who have a brain injury. Training must commence within 28 days of receipt of a letter (sent by the CSCI – 22 November 2006). The CSCI must be provided with official documentation to demonstrate that this training has been secured for commencement within 28 days. A concern letter was issued which included this requirement. 20/12/06 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 28 YA34 12 13(6) 19 13 YA35 18 The registered persons must be able to provide evidence at all times that staff have been checked on the POVA list and the date of the CRB. The registered persons must ensure that newly appointed staff are provided with a suitable work programme. Timescale of 10/02/06 not fully met. 01/12/06 21/12/06 14 YA39 24 The registered persons must ; Produce an annual development plan. Have in operation a monitoring system to self audit the performance of the home against all National Minimum Standards for Younger Adults. 01/02/07 15 YA42 13(4)(a) ( c) The registered persons must ensure that risk assessments are in place to ensure that risk is minimised/eradicated where service users have access to water temperatures that are in excess of 43oC. 01/12/06 16 YA42 13(4)(a) ( c) The registered persons must ensure that all wardrobes are suitably secured. In the interim risk assessments must be in place for each room to minimise/eradicate risk. 21/12/06 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 29 17 YA42 13(4)( c) 23(4)(e) The registered persons must ensure that all staff ; Are included in regular fire drill and that evidence is available to demonstrate this. All staff receive appropriate first aid training. Arrangements must be made for both of these areas to be actioned ( for example training booked by the timescale set). . 15/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA22 Good Practice Recommendations The registered persons are strongly advised to send written confirmation to complainants of the outcome of any complaint investigation and that it is detailed in the letter a timescale for them to respond if they are not satisfied with the outcome or actions taken. 48 Cedar Road DS0000063797.V320620.R02.S.doc Version 5.2 Page 30 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. 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