CARE HOMES FOR OLDER PEOPLE
Annabel House 6 Clifton Street Stourbridge Dudley West Midlands DY8 3XR Lead Inspector
Mrs Jean Edwards Unannounced Inspection 27th February 2006 08:30 X10015.doc Version 1.40 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 Annabel House DS0000024976.V284103.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 Older People. 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. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Annabel House Address 6 Clifton Street Stourbridge Dudley West Midlands DY8 3XR 01384 397104 NONE 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 D L Braham Lisa Braham Care Home 9 Category(ies) of Learning disability over 65 years of age (9) registration, with number of places Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3 service users (female) with a dual diagnosis of LD/MD currently living at the home may be accommodated for as long as the home is able to demonstrate that their needs can be met. 4 service users in the category of LD currently living at the home may be accommodated for as long as the home is able to demonstrate that their needs can be met. Date of last inspection 12/09/05 Brief Description of the Service: Annabel House is registered to provide care to a maximum of 9 service users. This Home is unusual in that it currently caters for a mixed age range, some being under 65 years the majority being over 65 years. The Home’s categories of registration are for people who have a diagnosis of learning disability (LD (E), Mental ill health / disorder (MD (E) or a dual diagnosis. Annabel House is a large detached property located in a residential area, near to the Stourbridge ring road. The Home comprises of two floors, with bedrooms located on each. t has a lounge and dining room, kitchen, laundry, office and toilet and bathing facilities available on both floors. There are seven single bedrooms and one double bedroom. The Home has a staff team of 9 people including the Registered Manager. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place over one weekday. The purpose of this visit is to assess progress towards meeting the national minimum standards for older people, with learning disabilities, and towards required improvements identified at previous inspection visits. A range of inspection methods has been used to make judgements and obtain evidence, which have included: discussions with the registered manager, the registered proprietor, and the staff. The majority of the eight residents accommodated were spoken at the time that they have been at home during the inspection process. A brief tour of the premises has also taken place. What the service does well:
The registered manager, supported by the proprietor has responded to the previous inspection report with an action plan, giving dates for the required improvements to be put into place. The registered manager is committed to making sure that improvements happen, where she has the authority to make decisions. Residents are encouraged by staff to treat Annabel House as their own home and to be as independent as they wish. Residents are able to make their own choices and there are residents meetings, with notes of discussions and decisions agreed. All sorts of topics are discussed including the running of the home, meals, activities, and celebrations. One resident had recently celebrated her birthday with other residents at the home, and she talked enthusiastically about the display of birthday cards on the sideboard in the communal lounge. People are able to attend daytime activities provided by the local authority if they wish. Some of the older residents now choose to stay at Annabel House and generally spend their time being taken out and about by the registered manager or members of staff. The premises are maintained to high standards and the home is clean, tidy and homely. Annabel House continues to have a small group of staff that have worked at the home for a long time and know the residents well. They are caring, committed and flexible, often willing to work extra shifts. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 6 This inspection was conducted with full co-operation of the registered provider, Registered Manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection?
The home has a new registered manager; the acting manager has successfully completed the CSCI registration process. She has worked at the home in various roles for many years and has achieved an NVQ 4 Care & Management and the Registered Managers Award. She demonstrates a strong commitment to her own and to the staff teams professional development to improve the services offered by the home for the benefit of the residents. The home has a detailed statement of purpose and service user guide, giving a range of information, for example about sizes of communal rooms and residents bedrooms, staffing arrangements, meals and so on. These documents are now readily available at the home and information about services provided by Annabel House, is now given to residents, relatives and other people interested in the home. One persons sister has signed to show receipt of her copy of the information. In addition there are now copies of the most recent inspection reports available in the home at all times. The Organisation has reviewed the contract / terms and conditions using the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Homes, however action has to be taken to issue or residence with a revised contracts. The revised contracts must show details of agreements reached for any financial arrangements, especially relating to contributions towards the minibus. There have been some improvements to plan of each persons care, with clearer guidance for staff and the plan now includes any restrictions of choice such as not going out and accompanied for safety reasons. The Registered Manager must ensure that the all healthcare screening processes and records are regularly reviewed and accurately show the current situation for each person. Progress is being made to provide fuller records of all health checks offered, together with outcomes and / or refusals (dental, optical, chiropody, auditory, annual health checks and regular health screening. Work is taking place with the health authority to provide each person with a health passport, giving fuller information on medical conditions and health care checks. The registered manager has put measures in place to improve the homes system for managing the residents medication needs, so that the system provides as many as safeguards as possible for the residents.
Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 7 There is now an activity programme records are maintained of individual residents participation or refusals. A recommendation has been made at this visit that this has produced in other formats, for example as pictures to make choices easier and more meaningful for residents. Minor repairs to the premises have been put in place since the last inspection, examples are that new doorbell has been installed, lock on the bathroom door has been replaced, and dor guard on kitchen door, used as a fire precaution has been repaired. Improvements have been made to infection control in the laundry, for example a laundry procedure is now displayed in the laundry area and a new cleaning schedule has been put in place. The registered manager has circulated questionnaires; the results of which will be analysed and action will be taken in any area requiring improvement. What they could do better:
Although, each person has a plan for their care, these do not contain enough information to make sure people are cared for properly. Each persons plan of how their care is to be given must contain short and long-term goals, details of how they are to be achieved under record of progress. Plans for younger people living at home must that they are person centred. The home must involve the residents and their relatives and pay careful attention to all aspects of the care required. The home’s complaints procedure must be produced in a form that is understandable to the people needing to use it. For example for people unable to read or understand written information, pictures, video or audio information must be provided. Similarly the home must develop alternative formats for residents to understand the choice of activities, menus and their rights to see their own records. The registered person must make progress to show that all staff are supported and trained to be aware of the needs and rights of vulnerable people. Additionally training needs to be put into place for staff to be able to respond appropriately to any behaviour from residents, which can be described as challenging. During the tour of the home of small number of minor repairs and improvements must carried out, for example in the ground floor bathroom the missing skirting board must be replaced and exposed pipes must be guarded or covered, to avoid residents being accidentally burned. The registered person must take action to deal with the staff call system within the home, which is not in working order and is currently deactivated. This must be modernised or replaced and individual risk assessments must be carried out relating to each residents needs as an interim measure.
Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 8 The staffing levels at the home may not be sufficient to make sure all residents are supervised, safe and have opportunities for stimulating social activities. Staff at the home continue to undertake many duties, which include caring, cleaning, catering, laundry and activities. The registered person is required to provide staffing proposals to the CSCI for consideration. The registered person must improve systems for dealing with residents financial affairs to show that all possible safeguards have been put in place. The home is required to make improvements to a number of areas of health and safety practices and records. Examples are that clutter must be removed from the laundry, cleaning products must be locked away at all times and access to the laundry must be restricted. Additional guidance must also be given to staff to follow good infection-control practices. 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. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): There is information about the running and performance of the home available and residents are encouraged to make their views known. Although progress has been made to update contracts/terms and conditions of occupancy, there are no revised contracts in place especially relating to residents financial contributions to the homes minibus. The home has not had any recent admissions. Standard 6 is not applicable. This home does not provide intermediate care. EVIDENCE: The majority of these standards have been assessed at the inspection visit in August 2005. The previous requirements have been reassessed at this visit and reprioritised timescales have been agreed where full compliance has not been demonstrated. The registered manager has revised and updated information about the home and there is evidence to that the statement of purpose and service user guide are available in the home at all times. The sister of one of the residents has signed to indicate receipt of a copy of the statement of purpose, service user guide and complaints procedure.
Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 11 Members of staff are able to talk knowledgeably about services provided for residents and they are aware of the recent inspection report, which is located in the office and is freely available. There is evidence that the contract / terms and conditions has been updated using the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Homes, which is good practice. However residents have not yet been issued with updated contracts, which must include agreement for financial contributions for the usage of the minibus for activities and where applicable agreement for the management of the persons financial affaires. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The care planning system in place continues to be developed and as yet does not adequately provide staff with the information they need to satisfactorily meet residents needs. The home has improved the arrangements for administration of medication, which generally safeguards the people living at the home. EVIDENCE: From the sample of residents case files assessed there is satisfactory evidence that there is a care plan in place for each person, based on their assessed needs. There are improvements in the level of information and guidance though plans must be more detailed and comprehensive. There are currently no short and long term goals identified and there is no further evidence of person centred planning in appropriate formats for the adults who are under 65 years. Despite some improvement daily notes completed by care staff still do not contain sufficient detail to show what level of assistance and care is provided and any outcomes. Following discussions during the inspection and advice given relating to a contact number, the registered manager is planning to seek support from the Dudley Learning Disability Forum.
Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 13 At the previous inspection there were two people identified as being at risk of self harm or displaying agitated behaviour; and one person identified as being at risk of swallowing food whole and chocking. At this visit there is insufficient evidence of appropriate written risk assessments and risk management strategies for staff to follow to ensure residents well being is safeguarded. However there are now moving and handling and falls risk assessments, for residents at risk. The registered manager has reviewed and expanded the homes medication policy procedures to reflect actual practice and has taken account of the guidance issued in June 2003 by the Royal Pharmaceutical Society of Great Britain. She has also improved the medication system, for example making sure (MAR) sheets contain details of residents’ allergies, GPs etc. and the home now has an up-to-date copy of the British National Formulary. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14 The majority of residents are supported to maintain some contact with family and friends, however there is not sufficient evidence that all residents are supported to exercise control and make decisions about their lives. EVIDENCE: The registered manager has made sure that there is an activity programme and there is a record maintained of individual residents participation, including a record of refusals. However it is stated that the activity programme is not always followed, as the residents may not wish to participate. It is strongly recommeded that activity planners are produced in alternative formats, for example pictorial, to assist residents to make meaningful choices. From the assessment of residents case files and discussions there is evidence that some residents have contact and support from their families. At least one sister, as next of kin, is involved in the residents care plan. The previous requirement to devise a policy relating to residents rights to have access to their personal records, remains outstanding. There are now records of the use individual residents make of the homes minibus, relating to a monthly charge of £13 per person levied. The registered
Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 15 manager states that despite efforts to involve other agencies there is no formal process to support individual residents make decisions about this expenditure. There is evidence from the tour of the premises and assessment of residents case files that people are encouraged to bring their personal possessions into the home if they wish, subject to health and safety considerations. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home has a generally satisfactory complaints system with evidence that residents and relatives feel that their views are listened to and acted upon. Arrangements for protecting residents are not yet satisfactory and may not safeguard them from risk of harm or abuse. EVIDENCE: The home has a generally satisfactory complaints procedure, which has been reproduced in larger print. However the only format is written and progress is needed to produce this and other important documents in alternative formats, suitable for residents accommodated. Discussions have taken place at this visit about the use of simpler language, pictures and symbols. There have been no complaints in the last twelve months. There are recording systems, to be used for any incident where physical or non-physical intervention techniques are used. However there is currently insufficient written guidance for staff when they may have to respond to a small number of residents with behaviours, which challenge the service. Progress must be made, as a priority, to provide all staff with up-to-date, approved training and awareness of all areas for the protection of vulnerable adults, including the use of physical and non-physical intervention techniques. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The standard of the décor within this home is generally good with evidence of improvement through continuing maintenance. This is a homely and comfortable environment for residents. EVIDENCE: Annabel House is a traditional detached property situated in a residential area of Stourbridge, local amenities are within walking distance and local towns are accessible by public transport. The interior and exterior of the premises are generally maintained to a satisfactory standard. The home is furnished with domestic and comfortable fixtures and fittings and has a homely atmosphere. The staff call system within the home, which currently is not in working order and is disconnected, must be modernised or replaced. The previous requirement for the Registered Manager to ensure that individual risk assessments are carried out and retained on file regarding the staff call facility in the bedrooms, as an interim measure, must be actioned. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 18 The tour of the premises showed that the Home is clean and free of any malodours. There is evidence demonstrating improved practices relating to food hygiene. Minor repairs are needed in the ground floor bathroom: replacement of the missing skirting board and provision of guards or covers for exposed pipes. The laundry area is generally well organised and some improvements have been made, examples are: there is a newly devised laundry procedure displayed in the laundry area and there is now a documented cleaning schedule for the laundry. However a risk assessment for any manual sluicing, where this cannot be avoided, has yet to be devised and implemented. Further improvements are required to remove all extraneous items / clutter from the laundry area and to ensure cleaning products are stored securely in compliance with COSHH Regs 1999. During the visit staff wearing white disposable aprons have been observed undertaking a range of tasks, in the laundry, kitchen and communal lounge, white removing the apron. The registered person must ensure that all staff adhere to good infection control practices and cease to use the same disposable aprons in the laundry and kitchen That colour coded disposable aprons are used for different tasks, for example blue for food handling. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 There is a stable, well-motivated staff team and residents receive consistent care. Recruitment practices have improved and provide safeguards for vulnerable adults. EVIDENCE: Annabel House has a staff team of 7 people in addition to the Registered Manager, As previously indicated an illustration using the Department of Health Staffing Forum Guidance identifies the need for 10.69 staff - Full Time Equivalent (FTE). Furthermore as previously discussed progress is required to demonstrate staff rotas include Managerial hours, total care hours worked by each person, ancillary hours, i.e. catering, domestic, and laundry. There are currently no staff vacancies, thought two staff are due to retire. There is evidence that all staff carry out a range of duties on each shift, such as cleaning, catering, laundry, care and activities. There are no additional ancillary staff employed at the home; and there is no designated activities coordinator or designated hours for activities. A staffing proposal must be forwarded to the CSCI office, Halesowen for consideration. Random samples of staff files examined are generally satisfactory. However there is no contract of employment on file and the registered person must ensure that each member of staff is issued with an accurate contract of employment, with a copy held on the personnel file. The home must demonstrate evidence that all staff have been issued with an individual copy of the CSCC (General Social Care Council) code of conduct & practice.
Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 20 The registered person must ensure that the hairdresser and any other selfemployed therapists provide the home with evidence of Public Liability insurance, qualifications and satisfactory POVA/CRB clearance. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37,38 The registered manager is effective in providing leadership and good clear communication systems throughout the home. The systems for resident consultation at Annabel House are generally good with some evidence that indicates that efforts are made to ensure that residents’ views are both sought and acted upon. EVIDENCE: Ms Lisa Braham has worked at Annabel House for many years, gaining promotion from care assistant to senior care assistant and has successfully completed the CSCI registration. She has achieved an NVQ for care and management award together with the Registered Managers Award (RMA), and demonstrates commitment to her own ongoing professional training and development. Residents and staff and feel that the registered manager is very approachable, supportive and people feel that they are able to tell her anything.
Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 22 There are clear lines of accountability within the home, with Lisa Braham, the Registered Manager in day-to-day control of the home and the Registered Provider, who must provide supervision, support and monitoring through monthly unannounced Regulation 26 visits and reports. The registered manager is in the process of devising a new annual development plan for the home. There are regular residents meetings and questionnaires have recently been distributed to residents and families and completed forms are in the process of being returned and views are being collated. The manager plans to feed back the results and take action in any area where there are concerns or where performance needs improvement. The registered manager has made commendable progress to ensure that regular reviews are carried out on the homes policies and procedures. These have been signed and dated by the registered manager, and continue to be monitored and amended as needed. The registered person continues to act as an agent for 6 residents, currently there are no financial records at the home, which can be assessed. The registered person must provide records of all incoming and outgoing payments, to be held securely at the home and be available for inspection. Additionally the registered person must provide evidence that the residents financial accounts managed by the home are independently audited. There is evidence that all staff receive supervision from the registered manager, and sessions are recorded. Topics covered include strengths and weaknesses, training needs, and new policies such as protection of vulnerable adults, Safeguard & Protect. Whilst this is commendable practice the registered manager is unable to achieve the required minimum 6 sessions per year for all members of staff due to workload. Alternative arrangements need to be put in place to free up time to achieve the target. During the tour of the premises it has been observed that there is free access for anyone to enter the laundry and for a time the cupboard used to store chemicals was left unlocked. The following improvements possibly made: the cupboard used to store COSHH materials must be locked at all times and the access to the laundry must be restricted on a risk assessed basis. A sample of fire safety and maintenance documentation examined is satisfactory. The Manager ensures that all staff receive mandatory training commensurate with their roles. For example recently all staff have received health and safety and food hygiene training in February 2006, using a computer program provided Highfields training. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 23 The accident records examined are generally satisfactory. There have been 4 accidents involving residents and 1 accident involving a member of staff since August 2005. Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 2 X X X 2 STAFFING Standard No Score 27 2 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 3 2 2 Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 25 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 OP2 Regulation 5(1)(b) Requirement 1) To ensure each person is issued with an appropriate document - contract / terms and conditions (for residents funded by the local authority), with the details of who is responsible for paying fees and responsibilities for any breaches (Timescale of 30/11/05 Not Fully Met) 2) To ensure that there is an upto-date signed and dated copy of the contract / terms and conditions on each residents file (Timescale of 30/11/05 Not Fully Met) 2. OP2 5(1)(b) The registered person must 01/05/06 include the detail of the management of each persons finances in their individual contract The Registered Provider/Manager 01/05/06 must explore further the appropriateness of the £13 per service user, per month mini bus charge. This fee must be discussed with the social workers allocated to the service users. If they approve this arrangement
DS0000024976.V284103.R01.S.doc Version 5.1 Page 26 Timescale for action 01/05/06 3. OP2 5(1)(b) 17(2)Sch 4 Annabel House 4. OP7 15(1) then it must be highlighted, that this fee is in place in the statement of purpose, service user guide and service users terms and conditions (Timescale of 31/10/04 and 30/11/06 Not Fully Met) 1) To ensure service user plans are signed by the service user / representative (Timescale of 31/10/04 and 30/11/05Not Fully Met) 2) To develop plans according to the principles of person centred planning, especially for younger service users (Timescale of 31/10/04 and 30/11/05 Not Fully Met) To continue the development and expansion of service user plans: 1) To clearly identify care needs, short and long term goals (Timescale of 31/05/05 and 30/11/05 Not Fully Met) 01/05/06 5. OP7 15(1) 01/05/06 6. OP7 15(1) 13(4) 01/05/06 1) To ensure that risk assessments and risk management strategies are devised and implemented for all areas of risk, such as risks of self harm, agitated behaviour and swallowing food whole (JD) (Timescale of 30/11/05 Not Fully Met) 2) To ensure that all documented risk assessments are available for staff guidance at all times. (Timescale of 30/11/05 Not Fully Met) 7. OP7 15(1) 13(4) 1) To devise and implement a risk assessments and risk management strategies relating to behaviours which challenge the service EG and JD
DS0000024976.V284103.R01.S.doc 01/05/06 Annabel House Version 5.1 Page 27 8. OP7 15(1) 17(1) 2) To implement behaviour monitoring charts to be evaluated for any resident with behaviours which challenge the service 1) To expand daily notes to provide fuller detail of care provided and outcomes (Timescale of 30/11/05 Not Fully Met) To ensure that all staff involved in the system of administration of medication have received accredited training for the safe administration of medicines (Timescale of 31/05/05 and 30/11/05 Not Fully Met) To revise the homes medication policy to include guidance for medication errors to show that any error must be notified to the CSCI in compliance with Regulation 37 To devise a policy relating to service users’ access to their personal records. (Timescale of 31/10/04 and 30/11/05 Not Fully Met) The Registered Provider/Manager must ensure that the homes complaints procedure is produced in formats to make it easier to understand by the residents. (for example pictorial / simplified wording) (Timescale of 31/10/04 and 30/11/05 Not Fully Met) To provide training for all staff in the use of physical and nonphysical intervention techniques (Timescale of 31/03/05 and 31/12/05 Not Met) 01/05/06 9. OP9 13(2) 01/06/06 10. OP9 13(2) 01/05/06 11. OP14 17(1) 01/05/06 12. OP16 22 01/05/06 13. OP18 13(5) 19(1) 01/06/06 14. OP21 23(2) The registered person must carry 01/05/06
DS0000024976.V284103.R01.S.doc Version 5.1 Page 28 Annabel House out the following in the ground floor bathroom: 1) To replace the missing skirting board 2) Provide guards / covers for exposed pipes The Registered Provider/Manager 01/05/06 must ensure that individual risk assessments are carried out as an interim measure, and retained on file regarding the staff call facility in the bedrooms. (Timescale of 31/10/04 and 31/12/05 Not Fully Met) 2) The staff call system within the home must be modernised/replaced. (Timescale of 31/10/04 and 31/12/05Not Met) 1) To devise and implement a risk assessment for any manual sluicing where this cannot be avoided (Timescale of 31/10/04 and 30/11/05 Not Fully Met) 1) To remove all extraneous items / clutter from the laundry area (Timescale of 30/11/05 Not Fully Met) 2) To ensure cleaning products are stored securely in compliance with COSHH Regs (Timescale of 30/11/05 Not Fully Met) 19. OP26 13(4) 23(2) The registered person must ensure that all staff adhere to good infection control practices and cease to use the same disposable aprons in the laundry and kitchen 1) To expand staff rotas to include Managerial hours, total care hours worked by each
DS0000024976.V284103.R01.S.doc 15. OP22 13(4) 23(2) 16. OP22 13(4) 23(2) 01/05/06 17. OP26 13(4) 23(2) 01/05/06 18. OP26 13(4) 23(2) 01/05/06 01/04/06 20. OP27 18(1)(a) 01/05/06 Annabel House Version 5.1 Page 29 person, ancillary hours, i.e. catering, domestic, laundry (Timescale of 31/10/04 and 30/09/05 Not Fully Met) 2) The staffing rotas must clearly and accurately show staff designations and identify the person responsible for the home on every shift 3) To forward revised staffing proposals, together with sample rotas to the CSCI office, Halesowen for consideration 21. OP29 17(2) 19(1) 1) To ensure that the member of staff is issued with an accurate contract of employment, with a copy held on her personnel file 2) The home must demonstrate evidence that all staff have been issued with an individual copy of the CSCC (General Social Care Council) code of conduct & practice. 22. OP29 17(2) 19(1) 1) To review and update the disciplinary and grievance procedures and staff contracts in view of the introduction of the protection of vulnerable adult abuse (POVA) register. (Timescale of 30/06/05 and 30/11/05 Not Met) 2) To ensure that account is taken of the guidance regarding POVA (Protection of Vulnerable Adults) clearances required for any persons, including volunteers, with checks implemented as required. (Timescale of 30/06/05 and 31/11/05 Not Fully Met) 01/05/06 01/05/06 Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 30 23. OP29 17(2) 19(1) 24. OP30 18(1)(c) 25. OP33 24 To ensure that the home has 01/05/06 copies of public liability insurance, POVA/CRB, qualifications for the hairdresser and any other independent therapists who may offer services to the residents at the home To provide staff training relating 01/05/06 to person centred care planning, especially for younger service users (under 65 years) with a learning disability (Timescale of 31/10/04 and 31/12/06 Not Fully Met) 1) The Registered 01/06/06 Provider/Manager must produce and implement quality assurance and quality monitoring systems. (Timescale of 31/10/04 and 31/12/06 Not Fully Met) 1) The Registered Provider, who must provide regular formal documented supervision for the registered manager 2) To ensure that documented Regulation 26 visit from the registered provider are conducted consistently on a monthly basis, with reports to the Home and the CSCI Satellite office – Halesowen. 1) The registered person acting as an agent for 6 residents must provide records of all incoming and outgoing payments, to be held securely at the home and be available for inspection 2) The registered person must provide evidence that the residents financial accounts managed by the home are independently audited The frequency of staff supervision sessions must be
DS0000024976.V284103.R01.S.doc 26. OP33 24 01/05/06 27. OP35 20(1) Sch 4(9) 01/06/06 28. OP36 18(1)(c) 01/05/06
Page 31 Annabel House Version 5.1 29. OP38 13(4) 18(1)(c) increased to a minimum 6 sessions per year The home must carry out regular environmental risk assessments; record the findings from these and details of any action required/taken. (Timescale of 31/10/04 and 30/11/05 Not Fully Met) To devise and implement a written food hazard analysis (Timescale of 31/10/04 and 30/11/05 Not Fully Met) Further expansion required 1) To provide accredited risk management training for all persons involved in undertaking risk assessments or engage the services of a ‘competent’ person to provide documented risk assessments, with control measures and risk management strategies. (Timescale of 31/05/05 and 31/12/05 Not Met) 2) To provide documentary evidence that approved risk assessment awareness training has been arranged for all staff to be delivered within an identified timescale. Timescale of 31/05/05 and 31/12/05 Not Met) 1) To ensure that all areas of risk associated with individual service users are clearly documented, such as challenging behaviours, personal safety within the Home’s environment and on any activities where the Home has a duty of care, especially outside the homes environment. (Timescale of 30/06/05 Not Fully Met) 01/05/06 30. OP38 13(4) 01/05/06 31. OP38 13(4) 18(1)(c) 01/06/06 32. OP38 13(4) 18(1)(c) 01/06/06 Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 32 33. OP38 13(4) 18(1)(c) 34. OP38 13(4) 2) To ensure that documented risk assessments and risk management strategies relating to the service users and the environment are reviewed, expanded and implemented. (Timescale of 30/06/05 and 31/12/06 Not Met) The registered person must 01/06/06 provide accredited health & safety training for the designated person (the registered manager) responsible for health & safety in the home 1) The cupboard used to store 01/05/06 COSHH materials must be locked at all times 2) The access to the laundry must be restricted on a risk assessed basis RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP8 OP10 OP12 OP15 OP26 Good Practice Recommendations That the Home obtains a summary or copy of the National Service Framework for Older People The Registered Provider/Manager should give consideration to providing suitable facilities for service users to meet with visitors in private That activity planners are produced in alternative formats, for example pictorial, to assist residents to make meaningful choices That menus are produced in alternative formats, for example pictorial, to assist residents to make meal choices That colour coded disposable aprons are used for different tasks, for example blue for food handling Annabel House DS0000024976.V284103.R01.S.doc Version 5.1 Page 33 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
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