Inspection on 15/02/06 for Alsop House

This inspection was carried out on 15th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alsop House 23/09/08

Alsop House 29/09/07

Alsop House 20/10/06

Alsop House 09/08/05

Alsop House 15/03/05

Alsop House 11/05/04

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOME ADULTS 18-65 Alsop House 2 Rowland Vernon Way Tipton West Midlands DY4 0RF Lead Inspector Jayne Fisher Unannounced Inspection 15th February 2006 09:30 Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 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 Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 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. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alsop House Address 2 Rowland Vernon Way Tipton West Midlands DY4 0RF 0121 557 2660 0121 557 2660 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) Sandwell Community Caring Trust Susan Coleman Care Home 6 Category(ies) of Physical disability (6) registration, with number of places Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation reported dated: 29 September 2005 may be accommodated in the category of PD(E) This will remain until such time that the service user no longer requires the respite service. 9 August 2005 Date of last inspection Brief Description of the Service: Alsop House is a purpose built bungalow located in a residential area of Tipton. The Home provides short stay respite care for up to six adults who have physical disabilities. All referrals must be made via Sandwell Social Services as the Department has a block contract with Sandwell Community Caring Trust to fund all six beds through out the year. There is a maximum stay of three months. This is a unique service; the only provision of its kind in the borough of Sandwell. There is a small car parking area at the front of the property. The garden is situated to the rear of the property. There is level access to the front and rear of the building. The Home was registered in February 2003. There are six single bedrooms all with ensuite shower facilities. Two bedrooms have overhead tracking hoists. There is also a bathroom with an overhead hoist. There is a lounge, and open plan kitchen and dining area. The Home has a conservatory which is also used as a smoking room. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between the hours of 9.30 a.m. and 3.00 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: case tracking, interviews with the manager and a member of support staff who were on duty. There was also a brief tour of the premises. Three residents were currently using the respite service, two of whom were happy to be interviewed and participated in the inspection. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of visits undertaken by the owner’s representative and an action plan submitted by the home following the last inspection. The majority of standards were examined at the last inspection and this report should therefore be read in conjunction with the previous inspection report to give a comprehensive overview. The inspector was made to feel very welcome and would like to thank service users and staff for their assistance and co-operation during the visit. What the service does well: Management and staff actively try to meet residents’ individual needs and requests. All residents are fully assessed whether they are new to the service or a constant user; as a result any changes in need are quickly identified and arrangements put in place to accommodate any extra requirements. Daily routines are flexible and very much person centred. Staff fully respect residents’ rights to privacy and dignity. There are a range of technical aids, adaptations and equipment to help residents maximise their independence. The premises is furnished to a high standard. All communal areas are light and airy with modern furniture. Residents can bring in their own possessions and equipment in order to make their bedrooms more homely. There is a stable staff group who are competent and well qualified. Staff and management demonstrate a patient, caring and conscientious approach to their roles and responsibilities. Whenever visiting the home there is always a relaxed and friendly atmosphere. An example of comments made by residents during this inspection include: “I can’t grumble about a thing. It’s perfect here”. “Staff are very friendly, they do whatever I ask”. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? The statement of purpose has been expanded and provides residents with an accurate description of the services provided. Residents have been invited to actively participate in reviewing policies and procedures and be involved in recruitment and selection of staff. There are regular residents’ meetings which are recorded and demonstrate that residents can choose what activities they would like to do and what outings they would like to undertake during their stay. There is on-going refurbishment and redecoration. inspection a new settee and chairs had been delivered. On the day of the Staff have undertaken a number of training courses in order to meet the specialist needs of residents. There is on-going work to complete outstanding requirements with regard to a small number of health and safety issues. 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. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 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 Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Comprehensive assessments are undertaken by the manager so that prospective and repeat users of the service can be confident that their individual needs and aspirations will be met. EVIDENCE: Progress was monitored at this visit towards outstanding requirements. It was pleasing to see that the statement of purpose has been amended as requested. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 9 As identified at previous inspections, there is a service user guide. However this is a generic document for Sandwell Community Caring Trust and must be individualised for Alsop House. For example, the Home does not accept self referrals as stated in this document. Accurate details must be included regarding staff employed and mandatory training. As a respite service there is a continual turnover of residents at Alsop House. There is a comprehensive assessment tool entitled ‘personal data sheet’ which assists staff in making judgements as to whether they can meet prospective residents’ needs. During interviews the manager demonstrated a competent and conscientious approach to assessing new, and existing users of the service. Where possible the manager will always visit the prospective service user in their home environment to assess needs and equipment. Staff obtain a copy of the placing officer’s care plan and assessment. It is commendable that staff closely monitor residents’ changing needs, and in the event that these have changed since their last admission, will proceed to arrange a review with the social worker and obtain an new and more up to date assessment of their needs. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not evaluated at this inspection. EVIDENCE: These standards were assessed at the last visit; progress was monitored towards outstanding requirements at this inspection. Care plans are basic in content but are supported by complex needs assessments which is suitable for the nature of a respite service. As previously identified, there are a couple of areas which do need some improvement. For example, where increased support in certain aspects of care is necessary, a more holistic care plan must be generated. One resident is prone to pressure sores but has no detailed care plan in place; there are no specific details with regard to catheter care or incontinence aids which are used at night. Both care plans and risk assessments require more regular updating to reflect residents’ changing needs. For example, one resident has deteriorating mobility and can no longer weight bear although risk assessments with regard to falls, mobility and transfers stated that they needed assistance to stand and did not mention that the resident now requires the assistance of an electric hoist. Another resident now requires a wheelchair for transfers inside the Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 11 home which is not mentioned in their care plan. There were no risk assessments in place with regard to tissue viability or incontinence. The content of risk assessments is basic and do not provide staff with sufficient guidelines regarding hazards and control measures. In some instances risk assessments are inaccurate as for example, staff do not complete medication administration record (MAR) sheets for residents who self administer their medication (other than to indicate they are self medicating). Staff have scored the risk assessments as high, medium or low but there is no scoring tool or suitable explanation to confirm how they have reached this conclusion. Whilst there are risk assessments in place for wheelchair users, risks associated with this equipment as highlighted by the Medicines and Healthcare Products Regulatory Agency have not been fully assessed. The manager is aware that there are shortfalls in the current care planning and risk assessment systems and will be addressing this with staff. At the last inspection management were asked to provide residents with opportunities for participating in the day to day running of the home and to contribute to development of the service, and review of policies and procedures. It was pleasing to see that there are regular residents’ meetings. In addition the manager has written to service users inviting them to take part in reviewing policies and recruitment and selection of staff. No response has yet been received. It has also been decided to abandon the issuing of feedback questionnaires at every admission but to send this out on a bi-annual basis in order to attempt to gather more in-depth feedback. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 16 Residents are offered opportunities to participate in social and leisure activities according to their own preferences and needs. Staff make efforts to ensure that daily routines promote residents’ independence and do not restrict their freedom or rights. EVIDENCE: Both residents who were interviewed expressed satisfaction with the level and type of activities provided at the home. Comments included: “I can’t praise them (staff) enough. We had a lovely Christmas”. “They make me feel really welcome, it’s not really like a home. If you want anything they will get it for you”. As previously requested, weekly meetings for residents have been re-instated as this is a useful forum for residents to discuss their wishes for the forthcoming week with regard to activities, meals etc. The last meeting took place on 13 February 2006 with good records maintained by staff of topics discussed. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 13 Unfortunately the home still has a vehicle with a foldaway ramp and a winch style hoist instead of a hydraulic hoist/tailgate. As a result staff encounter difficulties when trying to transfer residents in larger wheelchairs, and electric wheelchairs cannot be used. Mobile residents also have difficulty in accessing this vehicle because of the lack of graduated steps. The manager states that public transport or private taxis can be used as an alternative option. At the last inspection staff felt that this was a limitation of residents’ choices and spontaneous outings cannot always take place. The recommendation will remain outstanding with regard to considering providing a more suitable vehicle. Interviews and observations made during this inspection provides ample evidence to confirm that residents’ rights are respected and responsibilities are recognised in their daily lives. For example, upon arrival at 9.30 a.m. only one of the three residents had chosen to get up. One resident was served breakfast in bed at 10.30 a.m. as according to staff they like to have a lie in until midday. One resident stated “I can get up when I want but I do need help from staff”. Residents’ privacy is respected and there are suitable locking mechanisms on bedroom doors and communal bathrooms. Through out the inspection there was positive interaction observed between staff and residents. The atmosphere was very relaxed and friendly with residents and staff gently teasing each other and laughing. At the last inspection there were a couple of requirements regarding meals and mealtimes. On examination of records staff need to ensure that they more consistently record residents’ chosen options from the daily menu. Nutritional screening tools are in place but as previously identified, these have not been fully completed and ideally should contain the ideal body mass index (BMI). They also need reviewing and updating if they are more than twelve months old. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The systems for control and administration of medication need improvement in order to reduce risks to service users. EVIDENCE: On examination of care plans it was established that residents are receiving ‘regular’ checks during the night time. The manager states that this is to ensure that residents are safe and well. This could be construed as compromising residents’ dignity and could lead to disturbed sleep. Night time checks should be determined on the basis of medical or behavioural needs. As a compromise the manager has been asked to review this practice and discuss with residents their preferences with recorded outcomes in their care plans (unless there is a justified medical reason for regular checks which should also be recorded). An evaluation took place with regard to medication practice. It is acknowledged (and also admitted by the manager) that the transient nature of the service, has increased the risks with regard to the control and administration of medication. Staff strive to allow residents to maintain responsibility for administration of their own medication (as they would do in their own family home), but at the same time also have to ensure the safety of residents and adhere to good practice guidelines and relevant legislation. It was pleasing to see that staff are currently undertaking accredited training in the safe handling of medication. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 15 There were some concerns identified at this inspection with regard to those residents who self administer and the difficulty that staff have in continually deciding whether residents are competent to undertake such tasks at each admission. Risk assessments need expanding and a competency tool would assist in this process. Medication brought in by residents is checked by a member of staff and instructions regarding dosages and quantities are written onto medication administration record (MAR) sheets. It is required that two staff sign the medication sheet to indicate that the correct instructions have been transcribed from dispensing labels onto these MAR sheets. Handwritten instructions must contain all details including strengths of medication to be administered. It was noted that in some cases instructions on dispensing labels on containers conflicted with handwritten instructions on the MAR sheets. The manager explained that staff have to rely on residents and/or relatives with regard to changes that may have been made since the original medication was dispensed. Or, if there is insufficient information on the label itself. It is therefore required that where there are these differences, signatures are obtained from residents or relatives to confirm that they have given staff differing information to that contained on dispensing labels with regard to administration (or clarification sought from the prescriber if possible). As a rule all medication received into the home is fully recorded as is good practice. There is however one exception where residents may bring in medication which has been dispensed into a monitored dosage system (MDS). Staff are not always signing to confirm receipt because as the MDS cassette box is too small, they cannot easily identify the number or type of medication. The manager agrees that an alternative container must be sourced in order for staff to carry out appropriate checks and recording. It was also confusing to find that one resident had two MDS cassette boxes, one of which was locked in the medication cupboard, the other locked in the resident’s bedroom (who self medicates). The medication in one of the MDS cassettes did not correlate with the dates of administration, with medication missing from different days. There were no written records to confirm why these discrepancies had occurred and what action had been taken. Support staff seemed to think that medication had been started on a different day to that indicated on the MDS cassette because a short course of antibiotics had not been dispensed correctly. Without appropriate records it was difficult to carry out an audit or to confirm that the resident had self administered the medication correctly. The manager agreed that this needed to be investigated further. Any other items discussed during inspection of these standards are contained within the requirements section of this report. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: These standards were evaluated at the last visit. Progress was monitored towards outstanding requirements. It is pleasing to see that staff have undertaken a vulnerable adult abuse awareness course with only a small number of staff still to carry out this training. Policies and procedures are still required to be obtained or amended with regard to vulnerable adult abuse. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 17 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 the following standard(s): These standard were not assessed at this inspection. EVIDENCE: These standards were evaluated at the last visit. A brief tour of the premises was undertaken in order to assess progress towards outstanding requirements. There is evidence of on-going refurbishment and redecoration. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Residents are well supported by a skilled and qualified stable team of staff. EVIDENCE: There are currently seven support staff employed. Five staff are qualified to NVQ II or above. Some staff are undertaking further vocational training. A number of staff have undertaken specialist training in a variety of subjects including bereavement, epilepsy, dementia, record keeping and autism. As requested staff have also undertaken training in diabetes awareness and continence management. A requirement to undertake training in challenging behaviour has been withdrawn following discussion with the manager. It is agreed that this training would be more appropriate on a basis of individualized need rather than generic. No new staff have been recruited therefore an evaluation of recruitment and selection procedures could not take place. Neither could an assessment of induction and foundation training for new staff which will be undertaken at the next visit (if a new member of staff has joined the team). Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 As far as is reasonably practicable, the health, safety and welfare of service users continues to be well promoted and protected. EVIDENCE: Progress was monitored towards outstanding requirements in relation to these standards. Outcomes are identified in the requirements section of this report. There were a small number of health and safety issues identified at the last inspection and the majority of these are receiving on-going action but are not yet fully completed. For example, the manager has obtained advice from the local fire service regarding the lack of a suitable fire exit in the office. Window suppliers have been contacted and visited to provide quotes for the work needed. Further advice has been given with regard to contacting the West Midlands Fire Safety Officers. Attempts have been made to ensure that contractors carrying out monthly testing of the emergency lighting system complete records to evidence their tests. However, this is still not being completed every month. An annual inspection of the system is due to be carried out next month. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 20 The bi-annual fire safety drill is over slightly due. The majority of statutory has now been provided to all staff which is commendable. There are some staff who have yet to take part in a bi-annual fire safety training course. As discussed, if the manager carries out any fire safety refresher training, this must be fully recorded. Improvements have been made in testing and recording fridge and freezer temperatures. Unfortunately, staff are failing to consistently check and record cooked food temperatures. Any other items discussed during this inspection are contained within the Requirements section of this report. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X X X X X X 2 X Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 6 Requirement Timescale for action 01/06/06 2 YA6 15 3 YA9 13(4)(c) To amend the Service User Guide, to include all of the information as required by the National Minimum Standards (NMS) for Younger People Standard 1.2. i.e. details of experience and qualifications of staff etc. To forward a copy of the completed document to the CSCI. (Previous timescale of 1/12/03 is partly met). To ensure that care plans cover 01/06/06 in sufficient detail all aspects of personal, social and heatlhcare needs, for example with regard to pressure area care or nutrition. (Previous timescale of 1/10/05 is partly met). To carry out individual written 01/05/06 risk assessments with regard to all aspects of care including: service users who self medicate, wheelchair users, service users undertaking activities in the kitchen etc. (Previous timescale of 1/10/03 is partly met). To expand risk assessments to include the level of risk identified and include the actual date of Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 23 review. (Previous timescale of 1/7/04 is partly met). To expand risk assessments with regard to pressure area care. (Previous timescale of 1/7/04 is not met). To review and update risk assessment with regard to use of the mini-bus ramp and new hoist/seat belt. (Not assessed at this visit). To introduce a recognised nutritional screening tool for assessing individual service users’ nutritional needs. (Previous timescale of 1/5/04 is partly met). 4 YA17 16(2)(i) 12(1)(a) 01/06/06 5 YA18 12(1)(a) 6 YA20 13(2) To ensure more consistent recording of service users chosen options from the daily menu. (Previous timescale of 1/11/05 is not met). To review the practice of regular 01/06/06 checks undertaken during the night in consultation with individual service users. Outcomes to be documented in individual care plans. 1) To review and amend the 01/06/06 medication policy to ensure it accurately reflects procedures at Alsop House. (Previous timescale of 1/11/03 is not met). 2) To ensure that all staff responsible for the administration of medication sign the administration of medication procedures. (Previous timescale of 1/11/03 is not met). 3) To organise accredited medication training for all staff in the safe handling of medication. Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 24 (Previous timescale of 23/12/03 is partly met). 4) To obtain written consent to administration of medication from service users who require staff to administer their medication with records held in individual care plans. 5) To introduce a signature sheet for the handover of medication keys. 6) To devise a system to ensure that where medication received into the home which is in monitored dosages systems, is fully recorded. 7) To improve systems for recording receipt of medication into the home and handwritten instructions on Medication Administration Record (MAR) sheets – to obtain two staff initials to confirm correct instructions have been recorded with regard to administration and dosages. 8) To ensure that staff fully record any discrepancies identified with quantities of medication brought into the home and record action taken. 9) To improve risk assessments to establish if service users are able to self administer medication (for example through competency tools). 10) To ensure that where instructions on dispensing labels differ from instructions given by service users and/or their relatives with regard to dosages, Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 25 that their written signatures are obtained to confirm that the information they have given is correct (or to seek clarification with the prescriber). 11) To improve record keeping with regard to MAR sheets – any gaps must be fully explored and explanations recorded on the back of the MAR Sheets. 12) To ensure that where variable dosages are administered, that staff consistently record whether they have administered one or two tablets. To provide all staff with training 01/06/06 in vulnerable adult abuse. (Previous timescale of 1/2/03 is partly met). To expand the vulnerable adult abuse policy to include the new procedures on the Protection of Vulnerable Adult (POVA) scheme. (Previous timescale of 1/12/05 is not met). To obtain a copy of the Department of Health guidance on the Protection of Vulnerable Adults Scheme (POVA). (Previous timescale of 1/12/05 is not met). To make the following improvements to the environment: 1) to clean (or replace) all stained carpets in communal and bedroom areas. (Previous timescale of 1/3/04 is partly met). 2) To ensure that bedrooms which have been fitted with Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 26 7 YA23 13(6) 8. YA24 23(2)(b) 01/06/06 French patio doors have suitable window ventilation. (Previous timescale of 1/3/04 is not met). 3) To provide wash hand basins in ensuite bathrooms at a suitable height for wheelchair users. (Previous timescale of 1/10/04 is not met). 4) To carry redecoration of bedrooms were paintwork has become damaged and worn. (Previous timescale of 1/7/05 is not met). 5) To comply with advice given by the local fire service: to source an exit from the new conservatory which is used as the managers office). (Previous timescale of 1/11/05 is partly met). To make the following 01/06/06 improvements to infection control: 1) To display risk assessment with regard to manual sluicing of soiled items in the laundry. (Previous timescale of 1/3/04 is not met). 2) To display information relating to the control of substances hazardous to health (COSHH) in the laundry area. (Previous timescale of 1/6/05 is not met). 10. YA35 18(1)(c) To ensure that the Home has a 01/06/06 training and development plan with a dedicated training budget, details of which are to be held on the premises and available for inspection. (Previous timescale of 1/5/04 is partly met). DS0000041325.V283650.R01.S.doc Version 5.1 Page 27 9. YA30 13(3) Alsop House To ensure that all new Staff receive induction and foundation training to standards specified by the Training Organisation Personal Social Services (TOPSS). Induction and foundation training records to be held on the premises and available for inspection. (Not able to be assessed in view of no new staff since last inspection. This will be reassessed at next inspection visit). To provide all staff with training in equal opportunities and disability equality. (Previous timescale of 1/12/ is partly met). 11 YA36 18(2)(a) To ensure staff receive a minimum of six recorded supervision sessions per annum. (Not assessed at this inspection visit). To continue to pursue plans to ensure that the manager is qualified to NVQ IV in care by 2007. To develop an effective quality assurance system to include feedback from service users’ relatives, stakeholders in the community: district nurses and general practitioners etc. (Previous timescale of 1/5/04 is not met). To obtain and hold information and documents in respect of persons carrying on, managing or working at a care home as listed in Schedule 2 and 4 of the Care homes Regulations 2001. (Previous timescale of 1/9/03 is partly met). To ensure that all staff receive 2 DS0000041325.V283650.R01.S.doc 01/06/06 12. YA37 18(1)(c) 01/06/06 13. YA39 24 01/06/06 14. YA41 17(2) 19(1)(b) 01/06/06 15. YA42 18(1)(c) 01/06/06 Page 28 Alsop House Version 5.1 fire safety training sessions per annum. (Previous timescale of 1/11/05 is partly met). 16. YA42 13(4)(a) 23(4) To make the following improvements to fire, and health and safety: 1) To ensure that the emergency lighting system is tested on a monthly basis with records maintained. (Previous timescale of 1/5/04 is not met). 2) To review and update the fire safety risk assessment in view of recent changes to the premises in respect of fire safety precautions (Dorguards etc). (Previous timescale of 1/6/05 is not met). 3) To ensure that the emergency lighting system is serviced on an annual basis (or more frequently if according to manufacturers specifications). (Previous timescale of 1/11/05 is not met). 4) To ensure that all staff participate in at least two fire drills per annum. Fire drill records need to include the names of staff who have participated in the drill. (Previous timescale of 1/11/05 is not met). 5) To ensure compliance with the Control of Substances Hazardous to Health Regulations 1998: to carry out written risk assessments for all substances. (Previous timescale of 1/11/05 is not met). To make the following DS0000041325.V283650.R01.S.doc 01/06/06 17. YA42 16(2)(j) 01/06/06 Page 29 Alsop House Version 5.1 improvements to food hygiene practice: 1) To provide a separate hand washing facility in the kitchen area. (Previous timescale of 1/5/04 is not met). 2) To ensure that all cooked food temperatures are checked and recorded on a daily basis as in compliance with the Food Safety (Temperature Control) Regulations 1995. (Previous timescale of 1/6/05 is partly met). The Home must provide a 01/06/06 business and financial plan which should be held on the premises and available for inspection. (Previous timescale of 1/5/04 is partly met). To ensure that there is a written report on the conduct of the home completed by the providers representative who is carrying out monthly visits. A copy must be provided to the Registered Manager and a copy forwarded to the Commission for Social Care Inspection. (Previous timescale of 1/12/05 is not met). 18. YA43 25, 26 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 Refer to Standard YA13 YA20 Good Practice Recommendations To consider the purchase of a more suitable or second vehicle in order to accommodate all wheelchair users. To check and record the temperature of the conservatory/managers office where drugs cupboard is DS0000041325.V283650.R01.S.doc Version 5.1 Page 30 Alsop House 3 YA23 located to ensure that this does not exceed the safe limit of 25 C. To obtain two signatures (either staff and/or service user) to confirm records of any financial transactions are correct. (Not assessed at this visit). Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 Page 31 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: 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 Alsop House DS0000041325.V283650.R01.S.doc Version 5.1 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. 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. 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