CARE HOME ADULTS 18-65
Brookvale Road, 54 54 Brookvale Road Olton Solihull B92 7HZ Lead Inspector
Joe OConnor Unannounced 15 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. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Brookvale Road, 54 Address 54 Brookvale Road Olton Solihull West Midlands B92 7HZ 0121 708 1553 0121 708 1553 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) Robinia Care West Midlands Ltd Miss Christine Higgins Care Home 3 Category(ies) of Younger Adults, Learning Disability registration, with number of places Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Should the standard of care within the home deteriorate due to the manager being responsible for two other homes, then an individual manager will be required. 2. That Christine Beverley Higgins completes a recognised accredited training programme in physical intervention by 30th September 2005. Date of last inspection 24 November 2004 Brief Description of the Service: The service provided at Brookvale Road consists of a domestic three bedroomed house situated in a residential area of Olton in Soilhull. The service is registered to provide accommodation and support three adults with learning disabilites. The current service users are three men. 54 Brookvale Road is in a road of similar properties and is within walking distance of local facilites. Soilhull town centre is accessible by bus or train, as is Birmingham City Centre. Each service user has single bedroom accommodation. The rest of the house, consisting of a lounge, dining room, kitchen, bathroom, and shower room is shared on a communal basis. There is also an office that is also used as a staff sleep in room Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the mid afternoon until early evening. Three service users were present two of whom conveyed their views about life in the home. The third service user had very limited verbal communication and was unable to contribute his views. A limited tour of the premises was undertaken. Service users care plans and risk assessments were inspected. A number of health and safety records were also sampled. The Inspector also spoke to two members of staff. Observations of care practices were also undertaken. What the service does well:
Service users live in premises where its external features are similar in design and structure to that of neighbouring properties and its purpose as a care home is not distinguishable. Two service users were able to provide their views about life in the home. One stated “We have our ups and downs” but I am happy here. The service user was pleased to be involved in a project with the manager and staff to re-design the back garden. Another service user commented that he found the manager to be supportive following a number of incidents where money had gone missing from his bank account. A social worker had recently visited and was assured that the social worker and manager was doing every thing they can to protect his money. The same service user also spoke of his enjoyment with a new placement at the Employment Preparation Team. Service users are able to access various healthcare professionals including a GP, Optician, Dentist, and Chiropodist. There was also evidence of service users receiving specialist input such as a Speech and Language Therapist and Consultant Psychiatrist for medication reviews. Staff will support service users when attending medical appointments although one service user stated he would on occasions manage to go by himself. Service users are encouraged to be independent and one service user was observed to go out to the local shopping centre to buy his own toiletries and was later observed to prepare his own tea. Service users have a range of activities during the day. One service user had just returned from a horse riding activity and had recently started at a college to do music and drama. Interactions observed between staff and service users were generally positive. A sample of service users’ care records found that there was detailed information with regard to how the needs of service users were to be met.
Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 6 There were risk assessments covering a range of activities including escorting service users in the community. What has improved since the last inspection? What they could do better:
There are poor relationships between certain members of staff and the manager, which is having an impact on the service users daily, lives and is potentially placing more vulnerable service users at risk. One member of staff was found to be un-cooperative and would not answer questions with regard to the running of the service. Another member of staff had disclosed his knowledge of one service user bullying another but some of his colleagues had not taken this seriously and did not refer any incidents to the manager. Two staff have been suspended due to concerns over their performance to do the job to an acceptable standard that meets the needs of the service users. There has been an all round failure of staff reporting concerns where there has been a suspicion or evidence of abuse between service users. There is a need for a more robust system in place of reporting such events and staff must be made fully aware of the consequences in failing to report any concerns with regard to the abuse of vulnerable adults. Following this inspection a letter of serious concern outlining these matters was sent to the manager and the Responsible Individual for the Robinia Group. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 7 Medication management needed improvement. There was evidence on the Medicines Administration Records or MAR sheets as they are known that some medication had not been booked in by staff prior to administration and that there was no evidence of where amounts of tablets left over from the previous MAR sheets had been carried over onto the new ones. Parts of the premises were found to require some improvements. The carpet in the lounge was found to be stained and dirty. There were a lot of cobwebs hanging from the ceiling. The settees in the lounge were covered in crumbs. An outstanding requirement for the radiators in the premises to be covered had not been addressed. Parts of the paintwork on the skirting boards were in need of re-painting. The staff recruitment records were not available for inspection as they were in a locked cabinet and the manager who was on leave had the key. This is unacceptable and action must be taken to ensure these are available for inspection at anytime by the CSCI. A requirement from the previous inspection for an increase in staff during the evenings had not been addressed. Action must be taken to address this to ensure service users are adequately protected during the evening. One member of staff on duty is not adequate for the current group of service users. Health and safety matters require improvement. The service has not always informed the CSCI of any incidents affecting the welfare of service users such as any injury and when service users have had to be administered PRN or when required medication following an incident of aggressive behaviour. There was no proof of worthiness certificate in place to confirm the condition of the electrical wiring for the premises. Procedures such as the one for the protection of vulnerable adults does not state clearly the need for any incidents to be referred to the CSCI as well as other agencies. It must have details of the local CSCI office. 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. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 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 Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 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 & 3 Service users needs are reviewed and re-assessed through the involvement of qualified professionals to identify any changes. The service does not have a rigorous approach to the protection and welfare of service users without independent agency involvement who are potentially placing at risk. EVIDENCE: Two service users spoke with satisfaction about the care and support received by staff. One service user had problems with money being removed from his account and from further discussion it was evident that the Police and a social worker were investigating these. The service user stated that he found the manager to be supportive with what had happened and was always letting him know what was going on. Another service user stated that he was satisfied with the support being given and was pleased to be involved in a project to refurbish the back garden. Some observations were made of staff interaction with service users that was generally positive. A sample of service users records indicated that the manager had introduced person centred plans including to provide more personalised information as to how the service was to meet the individual needs. There have been no new admissions since the last inspection although there was written evidence to confirm that one service user was being seen by a social worker for a reassessment of his needs due to the need for an increase staff support when going out in the community.
Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 10 While there was evidence that certain aspects of the service users needs were being met; there were a number concerns relating to the performance and attitude of staff and the protection of service users’ welfare, where there is a lack of adequate systems to raise concerns. Two staff had been suspended prior to this inspection and there was no information available as to whether the staff members’ posts had been covered to maintain appropriate staffing levels. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 & 9 How service users needs are to be met are set out in detailed person centred plans. These cover service users individual likes and dislikes and their essential lifestyle. Service users have risk assessments in place that ensure staff are aware of how service users are to be escorted and supervised in the community. Service users are encouraged to make decisions about their lives through with the assistance of staff in weekly meetings. EVIDENCE: Two service users records were sampled and there was evidence that the manager had introduced person centred plans that covered their essential lifestyles and daily preferences. The person centred planning documents also had photographs of the service users. One person centred plan covered details as to what means of communication should be used including sign language. There was evidence of the service users being involved in their development with the support from relatives. Since the last inspection the organisation has introduced a new care planning format covering specific aims and objectives. Evidence was in place to confirm that the care plans were being reviewed every month. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 12 There risk assessments in place and these covered areas such as going out in the community unsupported and there was evidence of escort guidelines for one service user who requires two to one support when going to college. Service users stated that they had a meeting every Sunday to discuss menu changes and any activities. Some of the minutes demonstrated that service users were being given the choice to have new towels and flannels in their preferred colour. Two service users had changed bedrooms and there was evidence that this had been discussed with the manager and that a written agreement was in place between both service users that had been reviewed. One of the service users stated he was so far happy with his new room. Consideration must be given in ensuring service users are reminded about the complaints procedure. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 15, 16 &17 The service ensures that service users with communication difficulties receive specialist support to assist with their personal development. Service users have access to leisure activities in the community. Service users routines are not subject to any unnecessary restrictions subject to their individual risk assessment. Service users have access to a varied diet and are encouraged to prepare their own meals with support from staff where necessary. EVIDENCE: Service users did not have any restrictions with regard to their daily routines. One service user is subject to certain restrictions as he is under supervision within current mental health legislation and is allowed limited periods of free time to go out to pursue his own interests and visit his family. The service user stated he had recently commenced training at the Employment Preparation Team and was enjoying his training in gardening and horticulture. Another service user had commenced a numeracy and literacy class at a local adult education centre. Another service user had gone out on a horse riding activity earlier in the day. Two service users were observed to go out and one stated he had his own front door key. A sample of service users records confirmed that they had contact with their relatives on a regular basis.
Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 14 Since the last inspection a vehicle has been provided which one staff member commented should give service users more opportunities to go out. There is one service user who has limited verbal communication and there was documented evidence to show that the manager had sought specialist input form a Speech and Language Therapist to develop a communication dictionary with the use of photos to support the service user to communicate more effectively. A sample of the menu records indicated that service users received a varied diet and one service user was observed to be preparing his own tea. Decisions with regard to the menus were found to be made during the weekly service users meeting. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Service users receive support with their personal care and choose when they require assistance. Service users are able to access community and specialist primary healthcare services through good recording systems. Medication management requires some improvement to ensure the good health of service users is promoted. EVIDENCE: The service has a predominant team of male carers so appropriate gender care is being provided to the three male service users. Two service users stated they were able to get up and go to bed when they wanted to. A sample of service users daily recording referred to instances where service users had completed personal care tasks. As previously mentioned one service user with limited verbal communication was being seen by a Speech and Language Therapist to develop a communication dictionary through the use of photographs. Service users records confirmed that service users had access to local healthcare services such as dentist, optician, GP and chiropodist. There was also evidence that service users had access to specialist support such as a Consultant Psychiatrist for medication reviews. A referral had been made for one service user to be assessed by a dietician. Staff writes monthly reports about any issues with regard to service users’ health although two seen did not have a date of when these were completed by staff. Each service user has a keyworker.
Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 16 Medication management in the home was found to require some improvement. The manager had updated the medication procedure since the last inspection. There were no gaps in recording on the Medicines Administration Records but it was noted that some boxed medication from the previous MAR chart cycle had not been carried over to the new charts. Some medication had not been booked in by staff prior to administration. There was also some excess medication that had not been returned to the supplying pharmacist. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 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 & 23 A complaints procedure is in place for service users that is available in a pictorial format. Staff are failing to protect service users from bullying and abuse, with no clear systems in place to report and monitor any concerns. EVIDENCE: There is a complaints policy and procedure that is available in an accessible format for service users. The Commission has not received any complaints since the last inspection, although it was noted the service had received one complaint. A record was maintained of the complaint and the action taken to investigate it. However, there was no confirmation to indicate whether the service user was happy with the outcome of the investigation. Two service users stated that they would be able to approach the manager if they wish to raise any issues. One service user was being seen by a social worker following concerns that money was going missing from his bank account. Prior to this inspection the manager had notified the CSCI of what had happened and had also notified the Vulnerable Persons Police Officer. The service user stated that he was happy with the way the manager had supported him with his difficulties. There were a number of areas for protection of service users that were of serious concern during this inspection. Service user’s daily records stated that staff on duty had observed unexplained bruising that had not been notified to the Commission nor was their evidence to confirm that the service user had received treatment from a GP. During the course of this inspection a member of staff disclosed that he knew this individual to have been bullied by another service user. Other staff were aware of these concerns but had not raised them with the manager. Additional examination of both service users’ daily records confirmed that such incidents of bullying had occurred.
Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 18 Another member of staff was unable to demonstrate his knowledge with regard to the service’s adult protection policy and procedures. The adult protection policy and procedures does not clearly state that staff must contact the CSCI as well as other agencies. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The premises are maintained to an acceptable standard but there are areas, which require some improvement Service users, are able to remove freely around the premises without any apparent hazards. Some improvement is required with regard to infection control practices. EVIDENCE: A partial tour of the premises was undertaken. The premises were found to be clean and tidy to a certain extent. However, it was noted that there were a lot of cobwebs hanging from the ceilings in the lounge and the settees were found to be covered in crumbs. The carpet in the lounge was found to be stained and in need of considerable cleaning. Some of the skirting boards were found to have chipped paintwork. The light pull cords in the bathroom and toilet were found to be dirty and in need of cleaning. This needs addressing, as there is a risk of cross infection. Requirements from the previous inspection had been addressed with the installation of liquid soap and disposable towel dispensers. A new low surface temperature radiator had been fitted in the hallway. The shower cubicle had been fitted with a showerhead. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Current staffing levels do not meet the needs of the current group of service users. They limit service users opportunities for more spontaneous activities in the evening and limit staff’s ability to protect vulnerable service users welfare and safety. The service fails to ensure that staff recruitment and training records are available for inspection at anytime. EVIDENCE: At the time of this inspection there were two staff on duty during the morning and afternoon with one member of staff covering the afternoon period and evening. A requirement from the previous inspection to increase the staffing levels during the evening had not been addressed. Action must be taken to address this, as one member of staff on duty in the evening is not enough to ensure those service users who are most vulnerable are protected from harm. One staff member on duty during the evening does not provide service users to participate in spontaneous activities of their choice. Two staff have been suspended prior to this inspection and there was no evidence available to ensure what contingencies were in place to cover these shortfalls. Staff recruitment and training records were not examined during this inspection as they were locked in a cabinet. The manager was on leave and was in possession of the key. The manager must be mindful that the Regulations are very clear that records with regard to staff must be available for inspection at anytime.
Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 21 Observations found that in general staff were interacting with service users appropriately. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 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 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) 38, 39, 41 & 42 There are poor working relationships between some members of staff and the manager that are potentially placing service users at risk. The organisation must be more robust in ensuring service users views about the service are frequently heard. The reports for these must demonstrate the organisation’s commitment to stamping out poor working practices. Service users health and safety requires further improvement to ensure matters from the previous inspection are addressed. The maintenance records for health and safety were generally up to date, but some records such as staff recruitment records should be available for inspection. EVIDENCE: The Manager was recently registered with the Commission prior to this inspection. She was on leave at the time of this inspection. It was evident that the manager has made some improvements for the benefit of the service users since the last inspection and two of the service users stated she was approachable and would listen to their concerns. However it is also evident that the service users have endured disruption to their routines following the suspension of two members of staff.
Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 23 There are issues around the relationships between certain staff members and the manager that are having an impact on the welfare of service users. A member of staff on duty refused to answer questions about the management of the service and instead raised concerns about the organisations’ petty cash system, which the member of staff alleged that there were occasions when staff would be short of money to pay for essential provisions such as tea and milk. The overall view as to the management of the service is that there is a breakdown of relationships between certain staff members and the manager. It should be noted that the difficulties with certain individual staff members centre on those who were working under the service’s previous owners. Discussion with the manager and the representative from the organisation following this inspection, found that those who were working for the previous company have been unable or have not accepted the fact that previous working practices were in some instances found to be unacceptable staff working long shifts and organising their own staff rotas for their own convenience. While it is acknowledged that the manager and Robinia is trying to address these matters there is concern that the protection of certain vulnerable service users has been overlooked and that urgent action is required to ensure service users have stability and feel their interests are being put first. A representative from the organisation visits the service but not occur on monthly. Given the issues of concern raised in this report these visits must occur on a monthly basis and the reports for these sent to the Commission. The records were generally up to date but the organisation and manager must be mindful that records with regard to staff recruitment must be made available for inspection at anytime. An examination of health and safety records was found to be satisfactory. There was evidence to confirm that the equipment for the prevention of fire had been tested and serviced. A fire recent fire drill had occurred prior to this inspection. New fire extinguishers and fire blankets had been installed. A risk assessment for the prevention of fire was in place. It was noted however; there was not up to date documentation to confirm the worthiness of the gas and electrical hard wring for the premises. There were a number of paving slabs in the back garden that were found to be uneven and have the potential to trip service users and staff. The kitchen was found to be clean and tidy and there was evidence that daily temperatures were being made for the refrigerator and freezers. The microwave oven was found to be in need of cleaning. Risk assessments are in place for equipment being used by service users in the kitchen. A requirement from the previous inspection for the radiators to be covered had not been addressed, although a previously stated low surface temperature radiator had been installed in the hall.
Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 24 The accident book was examined there had only been two accidents involving service users since the last inspection. One entry referred to a service user having unexplained bruising which had not been notified to the Commission. An examination of the individual’s daily records found that there was an incident when PRN medication had to be administered as a result of the same service user demonstrating aggressive behaviour and this had also not been reported to CSCI. Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 25 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 1 x x Standard No 22 23
ENVIRONMENT Score 2 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 3 3 x x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 1 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Brookvale Road, 54 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x 1 2 x 1 1 x v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 26 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 3 Regulation 13(6) Requirement The Registered Person must ensure that service users needs and interests are protected through clear systems of recording to enable staff to raise any concerns. The Registered Person must ensure that service users are reminded about the complaints procedure during their weekly meetings. The Registered Person must ensure that the Medicines Administration Records (MAR charts) indicate where balances from the previous cycle have been carried over. The Registered Person must ensure that all medication is booked in prior to dispensing. The Registered Person must ensure that alterations to the MAR Charts are clearly stated and the reasons for these. The Registered Person must ensure that when investigating complaints that it states on the investigation record whether the service user was satisfied with the outcome. Timescale for action From 15 June 2005 Ongoing 2. 7 12(3) 15 July 2005 and Ongoing From 15 June 2005 Ongoing. 3. 20 13(2) 4. 20 13(2) 5. 20 13(2) From 15 June 2005 and Ongoing From 15 June Ongoing From 15 June and ongoing 6. 22 22(1) Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 27 7. 23 13(6) 8. 23 13(6) 9. 24 23(2)(d) 10. 24 23(2)(b) (d) 13(3) 11. 30 12. 33 18(1)(a) 13. 38 12(1)(a) 14. 39 26(1)(4)( a,b,5)(a) The Registered Person must ensure that there are robust procedures in place for responding to suspicion or evidence of abuse or neglect that protects the safety of service users. The adult protection policy and procedure must state clearly that any evidence or suspicion of abuse and neglect is reported to CSCI without delay. The Registered Person must ensure that the carpet and both settees in the lounge are cleaned to an acceptable standard. Cobwebs must also be removed. The Registered Person must ensure that the paintwork on the skirting boards is re-painted and made good. The Registered Person must ensure that the dirty light pull cords in the toilet and bathroom are replaced, ensuring the prevention of cross infection. The Registered Person must ensure that appropriate staffing levels are maintained during the evening to enable wider opportunites for service users to particpate in activites, but to also provide adequate cover in the home. Outstanding Requirement Timescale 24 January 2005 not met and is carried forward. The Registered Person must ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. Visits from the representative of the organisation must occur every month and ensure service users and staff are able to comment about life in the home. July 2005 and Ongoing July 2005 and Ongoing 15 July 2005 15 July 2005 15 July 2005 15 July 2005 From 16 June 2005 From 15 July 2005 and Ongoing
Page 28 Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 15. 41 17(3)(b)2 16. 42 13(4) 17. 42 13(4)37(1 )(c )(e) 18. 19. 42 42 13(3)(4) 13(4) 20. 42 13(4)23(2 )(c ) Reports from these visits must be forwarded to the Commission. The Registered Person must ensure that records with regard to staff recruitment and training are available for inspection at anytime. The Registered Person must ensure that radiator covers are in fitted in the home Outstanding Requirement. Timescale 25 January 2005 not met. The Registered Person must ensure that any incident that adversely affects the welfare and protection of service users is notified to the CSCI without delay. The microwave oven must be cleaned to an acceptable standard. The Registered Person must ensure that action is taken in ensuring the uneven paving slabs in the back garden are levelled to reduce the risk of service users and staff tripping. The Registered Person must ensure that it provides the following documentation: Gas Landlords Safety Certificate. Certification to confirm the proof of worthiness of the electrical hard wiring for the premises. From 15 June 2005 and Ongoing 15 July 2005 From 15 June 2005 and Ongoing 15 July 2005 15 July 2005 15 July 2005 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 Good Practice Recommendations Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Brookvale Road, 54 v231685 e54 s43666 54 brookvale road v231685 150605 stage 4.doc Version 1.30 Page 30 - 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!
