Inspection on 12/09/05 for Annabel House

This inspection was carried out on 12th September 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Annabel House 27/09/07

Annabel House 05/09/06

Annabel House 01/03/06

Annabel House 18/01/05

Annabel House 17/06/04

Annabel House 21/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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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 HOMES FOR OLDER PEOPLE Annabel House 6 Clifton Street Stourbridge Dudley West Midlands. DY8 3XR Lead Inspector Jean Edwards Unannounced 12 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Annabel House Address 6 Clifton Street Stourbridge West Midlands. DY8 3XR 01384 397104 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs D. L. Braham Mrs D. L. Braham Care Home 9 Category(ies) of OP Old Age (9) registration, with number of places Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 2. 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 18/01/05 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. It 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 E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced 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 included: discussions with the registered manager who is also the owner, and the staff. The majority of the eight residents accommodated were spoken to, with longer chats with four residents at home during the inspection process. The visit included a brief tour of the premises. What the service does well: The proprietor / registered manager and acting manager responded to the previous inspection report with an action plan, giving dates for the required improvements to be put into place. The acting 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. A range of topics is discussed, with views freely aired about the running of the home. All residents are able to go on an annual holiday if they wish. This years two week holiday in Rhyl has recently taken place in August and all residents chose to go together, supported by volunteers from the staff group. 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. The meals are thoughtfully and well prepared, members of staff were seen to ask residents what they preferred for each meal, and taking time to sensitively offer people help if they need it, after serving food. The residents who are able to speak say that they are very happy with the meals provided. The premises are maintained to high standards and the home is clean, tidy and homely. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 6 Annabel House has 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. This inspection was conducted with full co-operation of the Registered Manager, staff and residents. The atmosphere throughout 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 produced a more detailed statement of purpose and service user guide, giving information about sizes of communal rooms and residents bedrooms. However the documents are not readily available at the home. This is important information about services provided by Annabel House, which must be given to residents, relatives and other people interested in the home. The Registered Person and acting manager have made a successful request to the CSCI to have an accurate certificate of registration, reflecting the change of group of residents. The majority are now older people who have a learning disability. The acting manager has produced written guidance for staff as part of each persons plan for their care, which states the level of help needed to deal with their post and written correspondence. In addition each residents choices and final wishes in relation to funeral arrangements are recorded on personal files. The homes complaints procedure has been updated to show the address and telephone number of the CSCI Satellite office in Halesowen. However the written format is not the most suitable for people living at Annabel House and other formats, such as pictorial, need to be developed with the residents. The home has improved written systems to be used to manage and monitor any incident of behaviour, which presents challenges. A new washing machine with an appropriate sluice cycle has been provided, which has improved infection control measures. There are plans to replace the flooring in the first floor bathroom in the near future. The Manager has taken steps to make sure that all care staff employed at the home are over the age of 18 years in accordance with the Care Homes legislation. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 7 The acting manager has made an application to the CSCI to become the registered manager. The process is in the final stages to assess her fitness to be registered. There are improvements to the level of information for each resident and there is now a complete case file in place for every resident. 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. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 9 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 standard(s) 1,2 Information about the running and performance of the home is not made proactively available. The home has not yet updated contracts/terms and conditions of occupancy, this has the effect that residents and their advocates may not have the best information regarding their rights and entitlements and any agreed restrictions. The home has not had any recent admissions. Standard 6 is not applicable. This home does not provide intermediate care. EVIDENCE: The registered provider and acting manager have provided copies of the finalised statement of purpose and service user guide to the CSCI office, Halesowen, which includes all communal and bedroom sizes. However there are no copies easily available at the home. Additionally there are no copies of the most recent inspection reports available at the home, which results in a lack of staff awareness of the areas needing improvement. There is an outstanding requirement for the homes contract / terms and conditions to be revised and updated taking account of the Office of Fair Trading publication Unfair Terms in Care Homes Contracts. At present there is Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 10 insufficient evidence that each person has an appropriate contract / terms and conditions, which is appropriately signed and dated. Discussions have taken place at previous inspection visits about the monthly charge of £13 towards the mini bus per made to each resident. There is no evidence that the outstanding requirement to explore further the appropriateness of this fee with residents, social workers or families has been met. Although the minibus has recently been used to transport all residents on their annual holiday, there is no written detail of the usage on a regular basis. The registered person must provide documentary evidence of the usage of the minibus for activities by each resident, on their individual case file. The new registration certificate for the home is appropriately displayed in the public area. This now accurately reflects the change of service offered by the home, as the majority of residents are older people with learning disabilities. The registration also includes variations for residents currently accommodated who would be outside the Homes’ Registration Category, e.g. LD (younger adults under 65 years) and people with a dual diagnosis such as Learning Disability and Mental Disorder Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 11 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 standard(s) 7,8,9,10,11 The care planning system in place is still in development and does not adequately provide staff with the information they need to satisfactorily meet residents needs. Although the health needs of residents are generally well met with evidence of good multi disciplinary working taking place on a regular basis, records are insufficient. The home has made good progress to improve the arrangements for administration of medication, which generally safeguards the people living at the home. EVIDENCE: There is a there is a care plan in place for each person, based on their assessed needs, and though there are improvements in the level of information and guidance, they are not sufficiently detailed and comprehensive. There are currently no short and long term goals identified and no evidence of person centred planning in appropriate formats for the adults who are under 65 years. Two people are identified as being at risk of self harm or displaying agitated behaviour; and one person is identified as being at risk of swallowing food whole (JD)) and chocking. There are currently no written risk assessments and risk management strategies for staff to follow to ensure residents well being is safeguarded. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 12 Additionally though staff are aware of the existence of some documented risk assessments, none are available for staff guidance at the time of this inspection visit. The previous requirement to devise and implement falls risk assessments, as required remains outstanding. Discussions with staff indicate that residents are supported to take opportunities for health checks. However the sample of residents case files examined did not contain adequate records of all health checks offered, together with outcomes and / or refusals (dental, optical, chiropody, auditory, annual health checks and regular health screening. The daily notes completed by care staff do not contain sufficient detail to show what level of assistance and care is provided and any outcomes. There are references in daily notes to incidents of agitated / aggressive behaviour, however staff are not noting any reasons or outcomes of increased medication administered. There is a medication system and staff are have received training and appear knowledgeable. However the system needs to be regularly monitored. For example the registered person must review the storage of medication stores and ensure that out of date or unwanted medicines are appropriately disposed. There is evidence that support is given to residents to be appropriately groomed and dressed. There are records of each person’s preferred name, and staff address residents in a respectful manner. There are records on each persons file about assistance required to deal with post and correspondence. From the sample of case files assessed and from discussions there is evidence that the previous requirement to establish each residents preferences, choices and wishes in relation to dying, death and funeral arrangements. Where wishes have been expressed, these are now recorded on each persons file or it is noted that there are no specific wishes. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 13 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 standard(s) 12,15 This home makes some planned and spontaneous activities available on a regular basis, though not all residents are aware of them or take advantage of socially stimulating opportunities. The meals at Annabel House are good, offering both choice and variety. EVIDENCE: Some efforts are being made to introduce activity programmes, especially for residents, who now choose to spend their days at Annabel House, instead of attending day opportunities provided by the Local Authority. However there is a lack of consistent evidence available to demonstrate that all residents have been consulted as to their preferred activities, hobbies, and outings. Staffing levels during this visit are insufficient to allow staff time to provide individual stimulation or outings. The arrangements during the day of this visit are that one senior member of staff would have been left on duty with 4 residents, two needing considerable supervision regarding risks of self harm and verbally aggressive behaviour. Staff also undertake a range of other duties such as cleaning, cooking and laundry, in addition to supervision and care of residents. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 14 There are no records of the use individual residents make of the homes minibus, despite a monthly charge of £13 per person levied. All residents have recently returned from two weeks on holiday at Rhyl, supported by the registered manager, acting manager, deputy manager and a member of night staff. The residents able to communicate state they enjoyed themselves. The home has records of menu choices for each meal and the food consumed by each resident. The records are completed retrospectively, which has the potential disadvantage that people may not be offered a balanced diet. Though it is acknowledged that residents are able to make their own choices. This could be improved with menus produced in formats appropriate to residents capabilities, such as pictorial. All catering is undertaken by care staff. Sensitive assistance is offered to people needing help or feeding. People consulted are very complimentary about the food provided. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 15 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 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 revised to show the address and telephone number of the CSCI Satellite office - Halesowen. However the only format is written and progress is needed to produce this and other important documents in alternative formats, suitable for residents accommodated. There have been no complaints in the last twelve months. The acting manager has devised recording systems, to be used for any incident where physical or non-physical intervention techniques are used. However progress must be made to provide all staff with up-to-date, approved training and awareness of all areas for the protection of vulnerable adults. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 16 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 standard(s) 19,21,22,24,26 There is a generally good understanding of the areas in which the home needs to improve with some planning in place indicating how this improvement is going to be resourced and managed. 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. There is no passenger lift; however, there are two single bedrooms situated on the ground floor for use by people who have limited mobility. The bedrooms situated on the first floor are accessed via a staircase. The dated call system Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 17 does not work and currently there is no mechanism for calling assistance, apart from shouting. Forward planning and consideration must be given to the ageing residents needs. There are three bathrooms, which are generally accessible to residents. The bathroom on the first floor has a bath with overhead shower, wash hand basin and toilet. The shower room has a walk-in shower, wash hand basin and toilet. On the ground floor is a bath with overhead shower and a bath chair, wash hand basin and toilet. All are decorated to a generally satisfactory standard and fitted with suitable pass locks. However the lock on the ground floor bathroom is currently defective and can cause someone to be locked in. There are plans to replace the flooring in the first floor bathroom. There are four single bedrooms and one double bedroom on the first floor and two single bedrooms located on the ground floor. A sample of rooms viewed with permission, are pleasant and contain personal possessions according to each persons wishes. The tour of the premises showed that the Home is clean and free of any malodours. There is evidence demonstrating generally good practice relating to food hygiene. However a number of improvements must be put in place, the items are also outstanding from the Environmental Health Report to the home dated 28 April 2005. The laundry area has been improved and there is a new washing machine with an appropriate sluice cycle, which ensures better infection control. Though further work is required to improve all areas of infection control. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 There is a stable, well motivated staff team and residents receive consistent care. However staffing levels are insufficient to ensure residents safety and social stimulation. EVIDENCE: Annabel House has a staff team of 7 people in addition to the Registered Manager, which is a reduction of one member of staff since the last inspection visit. 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. The previous requirement apply the formula, taking account of the assessed needs of service users and forward staffing proposals to the CSCI for consideration, remain outstanding. This must be actioned as a priority. During this visit there is insufficient evidence from staffing rotas that adequate staffing levels are being maintained and on the morning of the visit the senior member of staff would be left alone on the premises to provide all aspects of care and attention for four residents, in addition to cooking the mid-day meal. This is an unacceptable serious situation, placing people at risk. The proprietor / registered manager has been requested to attend the home and provide additional staff, with immediate effect, as an immediate requirement. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 19 The Registered Person has taken steps to make sure that all care staff employed at the home are over the age of 18 years in accordance with and immediate requirement issued at the previous inspection in January 2005 and in compliance with The Care Homes legislation 2001. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,37,38 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: The Registered Manager is currently also the Proprietor, Mrs Diane Braham, who has owned and managed Annabel House since it opened. The acting manager, Mrs Lisa Braham has made an application to the CSCI to become the registered manager. The process is in the final stages to assess her fitness to be registered. The previous requirement for the home to produce an annual development, with continuous self monitoring, evidencing the involvement of residents, representatives and other community stakeholders, has not yet been fully met. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 21 Record keeping at the home shows some improvement, achieving better standards; however further improvements are required at this visit. Mandatory training records, fire safety and maintenance documentation examined identified deficits. A number of the service maintenance certificates are not available for inspection and copies must be submitted to the CSCI office, Halesowen. The registered person must ensure that all staff receive mandatory training commensurate with their roles; fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training, commensurate with duties undertaken. The accident records examined are generally satisfactory. There has been 1 accident involving a resident and 1 accident involving a member of staff since January 2005. However one of the accident records was incomplete. This must be rectified. Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 2 x x 3 3 2 STAFFING Standard No Score 27 1 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 x 2 x x x 2 2 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 23 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 1 Regulation 4 Requirement 1) To ensure that the statement of purpose and service user guide are available in the home at all times. 2) To provide documentary evidence that the statement of purpose, service user guide and complaints procedure have been made available to residents and their families. 3) To ensure that the most recent inspection reports are available in the home at all times. To review the contract / terms and conditions using the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Homes (Timescale of 31/10/04 Not Met) 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 for action 30/11/05 2. 2 5(1) (b) 30/11/05 3. 2 5(1) (b) 30/11/05 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 24 4. 2 35 5(1)(b) 17(2) Schedule 4 5. 2 12 35 7 5(1) 12(1) 17(2) 15(1) 6. 7. 7 15(1) 2) To ensure that there is an upto-date signed and dated copy of the contract / terms and conditions on each residents file The Registered Provider/Manager 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 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 Not Fully Met) To provide documentary evidence of the usage of the minibus for activities by each resident, on their individual case file The Registered Provider/Manager must ensure that each service users care plan includes detailed information about how the individual care needs is to be met and an individual risk assessment. (Timescale of 31/10/04 Not Fully Met) 1) To ensure service user plans are signed by the service user / representative (Timescale of 31/10/04 Not Fully Met) 2) To develop plans according to the principles of person centred planning, especially for younger service users (Timescale of 31/10/04 Not Fully Met) To continue the development and expansion of service user plans: 1) To clearly identify care needs, short and long term goals 30/11/05 30/11/05 30/11/05 30/11/05 8. 7 15(1) 30/11/05 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 25 2) To include clear guidance for staff, monitoring and evaluation processes 3) To include any restrictions of choices and freedoms, such as going out, bathing unaccompanied etc. (Timescale of 31/05/05 Not Fully Met) To develop documented risk 30/11/05 assessments and risk management strategies with the service users, especially relating to their personal safety to be held on their individual plans. (Timescale of 31/10/04 Not Fully Met) 1) To ensure that risk 30/11/05 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) 2) To ensure that all documented risk assessments are available for staff guidance at all times. 1) To expand daily notes to 30/11/05 provide fuller detail of care provided and outcomes 2) To ensure daily notes make reference to incidents of agitated / aggressive behaviour and the reasons and outcomes of increased medication To devise and implement falls risk assessments, as required (Timescale of 31/10/04 Not Fully Met) To provide records of all health checks offered, together with outcomes and / or refusals (dental, optical, chiropody, auditory, annual health checks and regular health screening 9. 7 15(1) 13(4) 10. 7 15(1) 13(4) 11. 7 15(1) 17(1) 12. 8 13(4) 30/11/05 13. 8 13(1) 30/11/05 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 26 14. 9 13(2) To provide the Commission for Social Care Inspection with a detailed and comprehensive action plan to include timescales for action relating to safe systems of medication administration for the following areas: 1) To review and expand the medication policy procedures to reflect actual practice in accordance with the guidance issued in June 2003 by the Royal Pharmaceutical Society of Great Britain. (Timescale of 31/05/05 Not Fully Met) 2) To maintain details of service users’ allergies etc, on the Medication Administration Records (MAR) sheets and provide guidelines for PRN medication in care plans. Timescale of 31/05/05 Not Met) 3) 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 Not Met) 4) To ensure the home has an up-to-date copy of the British National Formulary (no more than 12 months old) Timescale of 31/05/05 Not Met) 30/11/05 15. 9 13(2) 1) To review and expand the homely remedies policy, for example to include guidance about the length of time medicines may be given (no more than 48 hours) 30/11/05 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 27 2) To seek written clarification regarding accreditation for training provided by Lloyds pharmacy 3) To ensure internal and external medication is stored seperately 4) To review the storage of medication stores and ensure that out of date or unwanted medicines are appropriately disposed The registered provider/ Manager must ensure that an activity programme is produced and that a record is maintained of individual service users participation (including a record of refusals) (Timescale of 31/10/04 Not Fully Met) To devise a policy relating to service users’ access to their personal records. (Timescale of 31/10/04 Not Fully Met) The Registered Provider/Manager must ensure that the homes complaints procedure is revised in format to make it easier to understand by the service users. The complaints procedure must be readily available to all service users and visitors to the home. (Timescale of 31/10/04 Not Fully Met) 1) To provide training for all staff in the use of physical and nonphysical intervention techniques Timescale of 31/03/05 Not Met) 2) To ensure that the use of any physical intervention techniques (restraint) have been agreed in a multidisciplinary arena, with decision is clearly recorded on Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 28 16. 12 12(1) 16(2)(m) 30/11/05 17. 14 17(1) 30/11/05 18. 16 22 30/11/05 19. 18 13 (5) 19 (1) 31/12/05 20. 18 13 (5) 21. 19 23(2) individual plans Timescale of 31/05/05 Not Fully Met) To ensure that there are 31/10/05 appropriate records, reports and actions taken in response to incidents of aggressive behaviour between residents, including Regulation 37 notifications to the CSCI To ensure all minor repairs are 30/09/05 rectified in a timely manner 1) To repair / or replace the defective door bell 2) To repair / or replace the defective dor guard on the kitchen door 3) To repair / or replace the defective lock on the ground floor bathroom / toilet 1) The Registered Provider/Manager must ensure that individual risk assessments are carried out and retained on file regarding the staff call facility in the bedrooms. (Timescale of 31/10/04 Not Fully Met) 2) The staff call system within the home must be modernised/replaced. (Timescale of 31/10/04 Not Met) To provide the Commission for Social Care Inspection with a detailed and comprehensive action plan to include timescales for action for improvements to infection control in the following areas: 1) To devise and implement and display a laundry procedure in the laundry area (Timescale of 31/10/04 Not Fully Met) 22. 22 13(4) 23(2) 31/12/05 23. 26 38 13(4) 23(2) 30/11/05 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 29 24. 26 38 13(4) 23(2) 2) To devise and implement a risk assessment for any manual sluicing where this cannot be avoided (Timescale of 31/10/04 Not Fully Met) 1) To devise and implement a documented cleaning schedule for the laundry 2) To remove all extraneous items / clutter from the laundry area 3) To ensure cleaning products are stored securely in compliance with COSHH Regs 4) To provide COSHH data hazard sheets / information for all chemical products used (also identified in EHO report 28/4/05) 1) The Registered Provider/Manager must maintain an accurate record of all the hours worked in the home. (Timescale of 31/10/04 Not Fully Met) 2) A recognised system must be used to review the number of staff required by the home to meet the needs of the service users and the carrying out of ancillary duties by care staff. (Timescale of 31/10/04 Not Fully Met) 1) To expand staff rotas to include Managerial hours, total care hours worked by each person, ancillary hours, i.e. catering, domestic, laundry (Timescale of 31/10/04 Not Met) 2) To obtain a copy of the Residential Forum Staffing Tool approved by the Department of Health, apply the formula, taking account of the assessed needs of 30/11/05 25. 27 18(1)(a) 31/10/05 26. 27 18(1)(a) 30/09/05 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 30 27. 27 18(1)(a) service users and forward staffing proposals to the CSCI Satellite office - Halesowen for consideration. (Timescale of 31/10/04 Not Met) 1) The Registered Person must Immediate provide additional care hours, increasing staffing levels with immediate effect to ensure that there is a minimum of two competent, experienced and trained staff on duty at all times during the wakeful day whenever more than one (i.e. 2 or more) residents at home. 2) The Registered Person must forward documentation, including revised staffing rotas for the next 4 weeks, to the CSCI Satellite office - Halesowen Area Office for consideration by 1700 hrs on Thursday 15 September 2005. In addition the rotas must include management hours, total care hours worked by each person and the number of catering, cleaning and laundry hours provided, which is a long outstanding previous requirement. To ensure that job descriptions are available on file for each member of staff (Timescale of 31/10/04 Not able to be assessed) 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 Not Met) 2) To ensure that account is taken of the guidance regarding POVA (Protection of Vulnerable 28. 29 17(2) 19(1) 31/11/05 29. 29 17(2) 19(1) 30/11/05 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 31 30. 30 18(1)(c) 31. 30 18(1)(c) 32. 31 9 33. 33 24 Adults) clearances required for any persons, including volunteers, with checks implemented as required. (Timescale of 30/06/05 Not Met) The Registered Provider/Manager must produce training and development programmes for staff that meet with National Training Organisation workforce training targets. (Timescale of 31/10/04 Not Fully Met) To provide staff training relating to person centred care planning, especially for younger service users (under 65 years) with a learning disability (Timescale of 31/10/04 Not Fully Met) The Registered Provider/Manager must hold a qualification, at level 4 N.V.Q in management and care (or equivalent) by 2005. (Timescale of 31/10/04 Not Met) 1) The Registered Provider/Manager must produce and implement quality assurance and quality monitoring systems. (Timescale of 31/10/04 Not Fully Met) 30/11/05 31/12/05 31/12/05 31/12/05 34. 36 18(1(c) 35. 38 13 (4) 18 (1) (c) 2) Regular reviews must be carried out on the homes policies and procedures. These must be signed and dated by the registered provider, monitored and amended where applicable. (Due for review Jan 05) The Registered Provider/Manager 30/11/05 must be able to provide evidence that all staff receive six supervision sessions in any twelve-month period. Appropriate records must be kept in relation to this. (Timescale of 31/10/04 Not Fully Met) 1) The registered provider / 30/11/05 Manager must keep up to date Version 1.40 Page 32 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc COSHH records for staff. Risk assessments pertaining to cleaning materials used must be carried out. (Timescale of 31/10/04 Not Fully Met) 2) The home must review all of the policies and procedures relating to arrangements for maintaining safe working practices. (Timescale of 31/10/04 Not Fully Met) 3) 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 Not Fully Met) These requirements are also reflected in the recent Environmental Health Inspection Report The Registered Person must forward a documented action plan with timescales to address issues identified in the EHO report dated 28 April 2005 To undertake a documented Legionella Risk assessment, with control measures implemented, to be forwarded to the CSCI satellite office, Halesowen (Timescale of 31/10/04 Not Met) To devise and implement a written food hazard analysis (Timescale of 31/10/04 Not Fully Met) 1) To investigate and resolve the fridge temperature registering 10C 2) To provide a digital food probe 3) To provide food safe wipes to Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 33 36. 38 13 (4) 18 (1) (c) 30/11/05 37. 38 13 (4) 18 (1) (c) 30/11/05 38. 38 13 (4) 18 (1) (c) 13 (4) 18 (1) (c) 30/11/05 39. 38 30/09/05 clean the food probe 4) To undertake regular documented calibration checks for the food probe 5) To document cooked food temperatures of all high risk foods 6) To provide disposable paper to replace tea towels (or document laundering arrangements) 7) To expand the kitchen cleaning schedule, including staff signatures 8) To ensure all foods are stored in accordance with manufacturers instructions (opened sauces in cupboard not refrigerated) 9) To label opened high risk foods with date of opening and use by date 10) to ensure that blue plasters are available in the kitchen 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 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 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 34 40. 38 13 (4) 18 (1) (c) 30/11/05 31/05/05 Not Met) 41. 38 13 (4) 18 (1) (c) 1) To ensure that all areas of risk associated with individual service users are clearly documented, such as moving and handling, challenging behaviours, falls, personal safety within the Home’s environment and on any activities where the Home has a duty of care. (Timescale of 30/06/05 Not Fully Met) 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 Not Met) 1) To remove all extraneuos items (Desenex, Athletes foot cream, Brolene eye ointment, germalene and Morrisons antiseptic cream from the first aid box 2) To restock the first aid boxes 3) To ensure that the health and safety poster is completed with all relevant information To submit copies of the following documents to the CSCI office, Halesowen: 1) Annual fire alarm service certificate 2) Annual fire extinguisher service certificate 3) Annual emergency lighting service certificate 4) Portable electrical appliance (PAT) test certificate (two weeks overdue) Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 35 31/12/05 42. 38 13 (4) 31/10/05 43. 38 13(4) 30/11/05 5) Annual Call System service certificate 6) 5-year fixed electrical wiring test certificate 7) wheelchair service / maintenance certificate 8) asbestos test 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. Refer to Standard 8 10 15 22 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 menus are produced in alternative formats, for example pictorial, to assist residents to make meal choices That the Registered Provider/Manager should consult with a suitably qualified person with specialist knowledge on the service user group regarding environmental adaptations, which may be required to meet the future needs of the service users. That staffing levels are monitored and reviewed using the DoH Residential Staffing Formula on a regular basis / as occupancy and dependencies fluctuate, to be recorded on the staffing rotas That the registered person should request individual names on the generic fire training certificate or individual certificates for each member of staff 5. 27 6. 38 Annabel House E55 S24976 Annabel House UN V246099 240805 Stage 4 E55.doc Version 1.40 Page 36 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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. 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