Inspection on 31/08/07 for 59 Whitehorse Road

This inspection was carried out on 31st August 2007.

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

Other inspections for this house

59 Whitehorse Road 16/01/07

59 Whitehorse Road 17/01/06

59 Whitehorse Road 21/06/05

59 Whitehorse Road 01/03/05

59 Whitehorse Road 21/09/04

59 Whitehorse Road 02/03/04

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 Whitehorse Road, 59 59 Whitehorse Road Brownhills Walsall West Midlands WS8 7PE Lead Inspector Dawn Dillion Key Unannounced Inspection 30th August 2007 12:00 Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitehorse Road, 59 Address 59 Whitehorse Road Brownhills Walsall West Midlands WS8 7PE 01543 361478 01543 378407 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) Mrs Jacqueline Anne Bernard Dorothy Jones Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2007 Brief Description of the Service: 59 Whitehorse Road is a home located on the outskirts of Brownhills, West Midlands, providing a residential service for younger adults who have a learning disability. The single storey property is accessible via public transport and close to local amenities. The home comprises of six single occupancy bedrooms, en suite are not provided. Bathrooms and toilets are in close proximity to bedrooms and communal areas. The home also provides a large lounge/dining room equipped with essential furnishings and fitments to provide a comfortable area for relaxation. People living in the home have access to a domestic style kitchen and a separate laundry. The home has ramps and grab rails making it easily accessible. Staffing is provided on a 24-hour basis to ensure the total support and supervision of people living in the home. The fees chargeable for the service provided at 59 Whitehorse Road is £692.96p and £919.34p for a one to one service, both fees are charged at a weekly rate. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced Key Inspection of 59 Whitehorse Road was undertaken within nine hours over two days. The inspection methodologies that were used, to establish the quality of care provided and the effectiveness of the management of the home, to promote quality, diversity and best practices entailed the examination of the records, relating to the homes policies and procedures. One person that use the service was interviewed during the process of the inspection, due to the limited communication skills of the other people living in the home, the Inspector was unable to communicate effectively with them. A tour of the property was undertaken to ensure that the environment and systems in operation, were safe and suitable in meeting the needs of the people using the service. What the service does well: A number of people living in the home have limited communication skills; hence, it was difficult to establish their views and opinion in relation to the service provided within the home. General observations and discussions with staff evidenced that they had a wealth of knowledge about the care needs of the individual. Staff were seen to interact and communicate with people in a positive manner and in a mode suitable to their understanding. People living in the home were provided with the necessary support to ensure that they were able to maintain links with their family and friends and to have a positive presence within their local community. There was a positive emphasis focused of staff training, having achieved a 100 National Vocational Qualification trained workforce. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The homes policies and procedures were inconsistent in providing up to date information, relating to the service available at the home. Records evidenced a physical intervention procedure, however, the Registered Manager confirmed that this technique was not used. The complaint procedure was not published in a format to promote the understanding of people living in the home. Care plans were very poor containing repetitive information, some of which were also inconsistent and out of date. It was difficult to establish the care needs of the individual and what level of support and assistance the individual required to ensure that they were able to live a fulfilled lifestyle. Risk assessments were also poor, failing to provide relevant information. One risk assessment did not identify that the person suffered with epilepsy and required the support of two carers whilst in the community. The homes medication systems and practices were not robust to ensure that people received their medication safely and in accordance to the direction from the prescribing General Practitioner. It is of concern that a number of requirements identified within the last inspection report had not been addressed. Please contact the provider for advice of actions taken in response to this Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 7 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. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to access the service, were provided with some information to assist them in establishing, whether the service and provisions would be suitable in meeting their needs. EVIDENCE: Discussions with the Registered Manager confirmed that the home had not had any new admissions within recent years. The homes Statement of Purpose provided information, relating to the service and provisions available. The Service User Guide provided insufficient information, to ensure that people wishing to access the service, were fully informed, to enable them to establish whether the home would be suitable to meet their needs. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 10 The homes admission process incorporated a Care Management Assessment prior to entering the home, of which provided the foundation for the development of the ‘Centre Life Plan.’ People wishing to access the service were offered a number of trial visits and an overnight stay before moving into the home. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of concise, up to date care plans failed to demonstrate that people were receiving the appropriate level of care and support to enable them to live a lifestyle of their choice. EVIDENCE: Information obtained during the Care Management Assessment (Pre admission assessment), provided the foundation for the development of ‘Centre Life Plan.’ There was also a ‘micro care plan’ in place. The care plans were dissected into various models of which was confusing and difficult to establish the individuals care needs, and the level of support and Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 12 assistance the individual required. Some areas of the care plan had not been reviewed to reflect the changing needs of the individual; this was noted in particular with reference to the current medication people were receiving. The Registered Manager confirmed that physical intervention was not used, however, the Inspector noted that there was a protocol in place. The Registered Manager informed the Inspector that staff had not received the relevant training and would not use physical intervention within their daily care practice. Care plans contained some valuable information relating to communication, having a diary in place to enable staff to communicate effectively with people. As previously identified within the contents of this report, it was difficult to condense the information relating to the individual care needs. General observations during the process of the inspection evidenced that people were given a choice relating to the routine within the home, however, care plans failed to identify how individuals were supported to make decisions in areas affecting their lifestyle. Risk assessments were very sparse containing very little information. One risk assessment made reference to one individual slipping on the laminated flooring, there was no mention of the person suffering with severe epilepsy, or issues relating to the individuals challenging behaviour and limited mobility. Information contained within people’s files stemmed back to 2004 and it was difficult to establish what was up to date information. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The model of service in relation to lifestyle, choice and decision-making was not clearly defined, to ensure that the daily routine within the home reflected the individual’s needs. People living in the home benefited from a positive emphasis focused on community presence. EVIDENCE: Discussions with the Registered Manager confirmed that 5 out of 6 people living in the home attended day care services throughout the week. This raised concerns relating to the model of service, to whether it was the individual’s choice to attend day care services. One person who lived at the home attended college and also had a work placement. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 14 The home had their own transport of which, enabled them to ensure that people had access to all leisure facilities within their local community. The Registered Manager informed the Inspector that people were also encouraged to use public transport. The Registered Manager confirmed that all people living in the home had or arrangements were in place, to enable them to have an annual break. One person was going on holiday with their parents, with others having a holiday with the home or the day care centre. Staff provided the necessary support to enable people to maintain contact with their family and friends. Discussions with staff and the examination of one persons care plan, identified that staff escorted an individual to visit her mother who lived a considerable distance away from the home. The Inspector queried the use of a baby monitor within one persons bedroom, the Registered Manager informed the Inspector that this individual preferred to spend most of his time in his bedroom and this was to monitored his activity. There was no emphasis focused on the lack of privacy or dignity demonstrated to this individual. The Registered Manager informed the Inspector that the monitor would be taken out of use immediately. Meetings were undertaken with people who lived at 59 Whitehorse Road, to ensure that they had some involvement in the management of the home. The examination of an agenda relating to a past meeting identified discussions about shopping, domestic chores, food and social activities. Due to the limited communication skills of people living in the home, the Inspector was unable to communicate effectively with individuals; one person however, expressed his contentment with his lifestyle, social activities and meals provided. There were no individuals in residence from the ethnic minority group or anyone with specific religious needs. The homes policies and procedures did not incorporate much information relating to equality and diversity. The examination of the menus identified a repetitive choice of food being provided for lunch. The lack of variation resulted with beef being offered as the main and the alternative choice e.g. beef stew or beef pie. One weeks menu offered beef consecutively for three days. Ample food provisions were in storage and the cleanliness of the kitchen was maintained to a high standard. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of emphasis focused on care planning failed to demonstrate that individuals were receiving the appropriate level of support to promote their health and welfare. EVIDENCE: Albeit, that staff members demonstrated a wealth of knowledge of the care needs of people living in the home and general observations by the Inspector evidenced, that staff interacted and communicated in mode suitable to the individual. The written formats of the care plans were poor and it was difficult to establish a holistic picture of the care needs of the individual and the level of support and assistance the person required. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 16 Records evidenced that people had access to relevant healthcare professionals if and when required. The Registered Manager informed the Inspector that no one living in the home had any specific cultural of religious needs. The examination of the homes medication system and practices identified that these were not entirely robust, there were evidently some confusion with what was ‘when required’ medicines (PRN) and non prescribed medicines (homely remedies). One medications label read, “as directed.” It was also noted that there was no top on the bottle, leaving the medicine exposed to contamination. Sun lotions/creams were not maintained securely. An unsecured small fridge located in the kitchen contained medicated cream and tablets and was accessible to people living in the home, putting them at risk and the integrity of the medicines could have been compromised. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service were not provided with a complaint procedure that was specific to promote their understanding or to enable them to express any concerns or complaints. EVIDENCE: People living in the home had limited communication skills and would require support in expressing their concerns or complaints. The homes complaint procedure was not produced in a format to promote the understanding of the people accessing the service. Information contained within the procedure was also out of date with reference to contact details for the Commission for Social Care Inspection. The home also had a pictorial complaint procedure of which failed to identify whom concerns should be shared with. The Commission For Social Care Inspection has not received any complaints within the last twelve months relating to the home. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 18 The examination of staff files evidenced that they had received Adult Protection training and the refresher training was scheduled for 2008. Two records and funds pertaining to individuals living in the home were examined one of which was accurate, it was noted that there was a minor deficit of £1.12p with the other account record. A requirement was identified within the last inspection report, that people living in the home must not fund from personal monies any items that are the responsibility of the home to provide. The Registered Manager confirmed that people’s accounts had not yet been reimbursed and the Registered Provider would ensure that all monies are returned by the end of October 2007. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The design and layout of the property was suitable in meeting the needs of individuals. The lack of emphasis focused on health and safety could compromise the safety of people living in the home. EVIDENCE: 59 Whitehorse Road is located in a residential area of Brownhills, West Midlands. The single storey property comprised of six bedrooms, en suite facilities were not provided but washbasins were installed in each bedroom. Bathrooms and toilet areas were in close proximity to bedrooms and communal areas. One bathroom was equipped with an assisted bath. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 20 The home provided a large lounge/dining area, equipment with essential furnishings and fitments. The examination of furnishings identified that the corner unit and wardrobes had not been secured to the wall to ensure the health and safety of people. People living in the home had access to a domestic style kitchen, a separate laundry area was also provided. Ramps and grab rails were also in place to assist individuals who have limited mobility. A large patio garden located at the rear of the property was accessible to people living in home, having views of neighbouring fields. Limited car parking was available at the front of the property. The general cleanliness of the home was of a high standard. The examination of records identified that there were three risk assessments in place relating to the environment providing conflicting information. Records evidenced that water temperatures within the two bathrooms were being monitored; this should be expanded to all areas to which people living in the home have access. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff group were skilled and were provided in sufficient numbers to support people who use the service. The lack of appropriate safety checks for all staff members compromised the safety of people living in the home. EVIDENCE: The examination of the ‘Training Need Analysis,’ in the last twelve months, identified that staff had received training in first aid, moving and handling, health and safety, food hygiene, epilepsy, fire safety and the safe handling of medicines. The Registered Manager informed the Inspector that the home had achieved a 100 National Vocational Qualification trained workforce. The Registered Manager also confirmed that staff had received accredited Learning Disability Award Framework (LDAF) training in adult abuse. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 22 Staff rotas identified that two staff were provided per shift, additional staffing were also provided to escort people to social activities and to ensure that they were always two staff working in the home. The rotas were clearly flexible to meet the needs of people living in the home. The home provided one wakeful staff and one person undertaking sleep-in duties throughout the night. The Registered Manager informed the Inspector that one person had commenced employment within the home since the last inspection visit. The examination of this staff members file, confirmed that all the relevant safety checks had been taken prior to the offer of appointment. Due to the challenging behaviours displayed by some people living in the home, a mobile hairdresser was used. There was no evidence that the hairdresser had been subject to a Criminal Record Bureau check or had appropriate Public Liability Insurance cover. A gardener was also employed and there was also no evidence that this individual had been subject to a Criminal Record Bureau check, the Registered Manager was confident that this person never accessed the building and did not have any contact with the people living in the home. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 23 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 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of a consistent style of management and evidence to demonstrate that peoples care needs were being met, in accordance to their individual assessment, failed to ensure the effectiveness of the delivery of the service. EVIDENCE: The Registered Manager was present for only part of the inspection, discussions with her identified that she had a number of years experience within social care and had achieved relevant qualifications pertaining to her Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 24 roles and responsibilities. She demonstrated a sound knowledge, of the care needs of people living in the home. There was however, a failing to provide concise up to date information within care plans and to ensure that policies and procedures within the home reflected the current services provided. With reference to systems in operation relating to quality assurance, the Commission For Social Care Inspection had recently received a report from the Registered Provider, relating to a monitoring visit. It is of concern that information contained within this report was very sensitive/personal breaching the confidentiality of one person living in the home. Questionnaires relating to the quality of the service provisions were issued to people, but it was difficult to establish the frequency of when these were distributed and how the information was collated and fed back to individuals. The examination of records and systems that promote the health, safety and welfare of people accessing the service and staff members evidenced the following: Records identified that portable appliance testing (PAT) was undertaken on the 05/09/06. There was a certificate of an electrical installation dated 26/11/03. A gas safety inspection was undertaken 15/09/03. The fire alarm was serviced in April 2007. The home records identified that the fire alarm should be checked on a weekly basis. Records identified that only 2 checks were undertaken in July. There was also a lack of consistency in checking the emergency lighting. A comprehensive fire risk assessment was in place, that also included a fire evacuation plan and information relating to what level of support and assistance the individual would require, to evacuate the premises in the event of a fire. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 2 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 1 X 3 X 1 X X 2 X Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 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 YA6 Regulation 15 Requirement Care plans must be in place for all identified needs that contain specific aims and goals for individuals. Essential lifestyle plans must be completed in full and be in a format accessible to service users. (Outstanding from 31/03/07). 2. YA9 13(4) Comprehensive risk assessments 15/12/07 must be completed for all service users based in their individual capabilities - part met. Requirement originally made January 2006. Risk assessments must be completed for any identified needs contained with plans of care - part met. Requirement originally made January 2006. (Remains outstanding). 3. YA20 13(2) All PRN ‘when required’ medication must be recorded on the medication administration records. 31/10/07 Timescale for action 01/12/07 Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 27 That ‘as directed’ instructions must be clarified with the general practitioner, with clear instructions obtained and recorded on the medication administration records. (Outstanding from the 01/02/07). 4. YA23 13(6) Service users must be reimbursed for purchasing furniture, bedding and towels. (Outstanding from 01/02/07). That the manager receives regular, formal supervision, with records maintained - part met. Requirement originally made January 2006. (Not examined at this inspection). 31/10/07 5. YA36 18(2)(a) 31/10/07 6. YA36 18(2)(a) That all staff receive at least six 31/10/07 formal supervision sessions per year, with records maintained. (Time scale identified as 31/03/07, this was not examined at this inspection). That all policies and procedures are reviewed and comply with relevant legislation and good practice guidelines. Particular attention must be given to: The complaints policy, The adult protection policy, The prevention of violence and aggression policy, The restraint policy, The management of service users monies policy; and 01/12/07 7. YA40 17 & 12(1) Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 28 8. YA41 17 & 12(1) The manual handling policy. (Outstanding from 31/03/07). An audit of all records maintain in the home must take place with records no longer applicable being archived. (Outstanding from 31/03/07. There was confusion to what was prescribed PRN ‘when required’ medicines and non-prescribed medicines ‘homely remedies.’ The registered person should ensure that the appropriate measures are put in place so that people receive their medication as directed by the General Practitioner. Medicines were stored within an unsecured fridge in the kitchen, of which, was accessible to people living in the home. The registered person should take the appropriate action to ensure that all medicines are securely stored. A bottle of medicine did not have a top on it, leaving the liquid exposed to contamination. The registered person should ensure that all medicines are stored appropriately, to ensure the health and welfare of people receiving medication. Wardrobes and a corner unit were not secured to the wall. To ensure the health and safety of people accessing the service, the registered person should ensure that furnishings do not pose a risk to the health and welfare of individuals. There was no evidence that the hairdresser had received a Criminal Record Bureau DS0000038819.V352301.R01.S.doc 31/10/07 9. YA20 13(2) 31/10/07 10. YA20 13(2) 31/10/07 11. YA20 13(2) 31/10/07 12. YA24 13(4)(a) 31/10/07 13. YA34 19, Schedule 2 & 43 15/11/07 Whitehorse Road, 59 Version 5.2 Page 29 clearance or was in receipt of a Public Liability Insurance. The registered person is required to take the appropriate action to ensure that people living in the home are protected. 14. YA39 24 There was no evidence that information collated from the quality assurance questionnaire was fed back to people who accessed the service, or what actions would be taken to improve the service delivery. The registered person should undertake the necessary actions to ensure that a robust quality assurance system is in place. Documents relating to the delivery of care and the homes policies and procedures, were not up to date or consistent in evidencing the service provided to people. The registered person should address the management of the home to ensure that there is sufficient evidence that people needs are being met appropriately. 05/12/07 15. YA37 21 02/01/08 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. Refer to Standard YA6 YA9 YA17 Good Practice Recommendations Staff should receive guidance to understand the principles of person centred planning. That risk assessments for the same area of risk are audited and information maintained in one document. That advice is sought regarding menu planning and DS0000038819.V352301.R01.S.doc Version 5.2 Page 30 Whitehorse Road, 59 4. 5. 6. 7. 8. 9. 10. 11. YA39 YA1 YA16 YA22 YA24 YA23 YA16 YA42 providing nutritionally balanced meals. That staff receive guidance in understanding what quality assurance is and why it is important. The Service User Guide to be reviewed to provide relevant information, relating to the service and provisions provided at the home. To review systems and practices that promotes the privacy of people living in the home and to discontinue the use of the baby monitor. The complaint policy should be reviewed to ensure that it is published in a format that promotes the understanding of people living in the home. The monitoring of water temperatures should be expanded to all water distribution areas that are accessible to people living in the home. To review the financial accounting of people’s money to ensure that system are entirely robust. To ensure that the daily routine of people accessing day care service is the choice of the individual. Fire safety checks should be undertaken consistently to ensure that systems are working effectively. Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whitehorse Road, 59 DS0000038819.V352301.R01.S.doc Version 5.2 Page 32 - 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. 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