Inspection on 09/06/05 for Conway House

This inspection was carried out on 9th June 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

Conway House 29/05/08

Conway House 29/05/07

Conway House 29/11/05

Conway House 12/01/05

Conway House 11/08/04

Conway House 13/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Conway House 44 George Road Oldbury West Midlands B68 9LH Lead Inspector Jayne Fisher Unannounced 9th June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Conway House Address 44 George Road, Oldbury, West Midlands, B68 9LH 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) 0121 552 1882 0121 552 1882 Mrs Julie Birks Mr Peter Birks Mrs Lynne Ann Strudley Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1), Physical disability (7), of places Physical disability over 65 years of age (1) Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2005 Brief Description of the Service: Conway House is a large bungalow which was originally built in 1954. It was converted and extended in 1994 to provide residential care for eight service users with learning and physical disabilities. The Home is situated on a suburban road, opposite a small row of shops and nearby public house. Access to the front of the Home is via a small parking area and a concrete ramp. There is a large garden to the side of the property and a sensory room situated to the rear of the house. There are eight single bedrooms, some of which have sliding doors which lead onto the patio and give a pleasant view of the garden. The decoration and personal belongings reflect the individuality of the residents. There is a lounge area, dining room and kitchen with a separate laundry. There are two large bathrooms with toilets. One bathroom has a bath with a Jacuzzi and a drying bench. There is an in-house day care provision for some service users. The Home provides a range of activities for service users. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between the hours of 9.45 a.m. and 1.00 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: formal interviews with the two members of staff who were on duty. There was also a tour of the premises which included visiting all communal areas, the kitchen, laundry, bathing facilities and service users’ bedrooms. Five residents were at home during varying stages of the inspection process. Open dialogue was not possible with residents therefore the inspector relied upon body language and observations of interactions between staff and residents. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of visits undertaken by the owner, notification of events sent to the Commission for Social Care Inspection and an action plan submitted by the home following the last inspection. The manager was on a training day and therefore not able to attend the inspection. However, she has produced a very useful action plan detailing ongoing progress made towards meeting outstanding requirements. Staff were also very helpful and co-operative through out the whole inspection process. What the service does well: Staff strive to ensure that they respect residents’ dignity and privacy and during interviews gave good examples of how this is maintained. Residents are given lots of choices and opportunities to be involved in the running of the home. For example, there are always two meals cooked for the main meal of the day and staff observe residents’ preferences by watching their body language. Residents looked happy and relaxed. They were dressed in clothing which reflects their tastes and personalities. Three residents enjoyed a relaxing foot spa on the morning, then all five residents went out to the nearby pub for a drink before coming back for lunch. The tables were nicely laid out. The food looked tasty and smelt appetizing. The lunch time meal was relaxed and unhurried with staff eating their meals alongside residents and assisting those who needed help in a professional manner. The home is furnished and decorated to a very good standard and provides residents with a homely and attractive place to live. Residents’ bedrooms are all individually decorated and furnished to suit their own tastes and preferences. There is a range of equipment to help residents maintain their Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 6 independence and well being. For example there is a hydrotherapy high-low spa bath. The home also has a separate and very well equipped sensory room. During interviews and observations staff demonstrated a caring and patient approach to their work. They know residents’ individual needs and how to meet them, and there is a detailed care planning system to help them. There is a thorough system for checking new staff to ensure that residents are protected from abuse. There is also a comprehensive complaints system. Staff will make complaints on behalf of residents if they feel their rights have been compromised. The overall findings of this inspection confirmed that the home continues to be extremely well managed, with caring staff who are maintaining the high standards of care. What has improved since the last inspection? 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. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 The homes Statement of Purpose and Service User Guide are very good, providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: The home has a comprehensive statement of purpose and service user guide. Slight amendments are necessary as indicated at the last announced inspection. It is pleasing to see that copies of the documents are placed in folders in service users’ bedrooms. Unfortunately copies of contract/statement of terms and conditions of occupancy were not available for inspection as these were held in a locked filing cabinet. These will be assessed at the next statutory visit. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 The home has a comprehensive care planning system so that staff are provided with detailed guidelines in how to provide care for service users. Only slight expansion is needed to allow service users more opportunities for participation in care planning and thereby giving them chances for identifying their aspirations and wishes. EVIDENCE: Care plans are comprehensive and cover a wide selection of subjects. Some care plans still need to be expanded with regard to for example pressure area care. These must include details of pressure relieving equipment and aids. Care plans also need to be established for epilepsy. It is pleasing to see that the home is continuing to strive to introduce a relevant person centred planning approach through essential life style planning. Staff report that they are still in the process of completing life story books to assist in this approach. There is a comprehensive risk assessment and management style. Some slight improvements are still necessary as previously identified. For example, by ensuring that all risk assessments identify a high, medium or low risk. Risk Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 10 assessments which have identified a ‘high risk’ (for example with regard to pressure area care) have not been reviewed since July 2004 and ideally must be reviewed on a more regular basis by virtue of the fact that they have been deemed high risk. Expansion is also necessary with regard to risk assessments and wheelchairs mainly due to new risks which have been identified by the Medicines and Healthcare Products Regulatory Agency. Information was supplied to the home on the day of the inspection. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards will be assessed at the next inspection visit. There is an outstanding requirement with regard to the funding of service users’ holidays. As service users have not yet been on their holiday this year, this will be assessed at the next statutory visit. As part of case tracking a new requirement has been identified. As required the home has carried out nutritional screening and assessments. These have identified that some service users require nutritional supplements and also that some have fluctuating weight. Nutritional care plans for these service users must be established with guidelines in respect of the nutritional supplements and any other eating strategies. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The systems for the administration of medication are improved although further progress is necessary in order to ensure service users’ medication needs are fully met. EVIDENCE: Since the last inspection there has been some improvement in the procedures relating to the control and administration of medication. A full evaluation will take place at the next statutory visit. At this inspection progress was assessed with regard to meeting outstanding requirements. It was pleasing to see that medication administration record (MAR) sheets are more accurately completed. There is now a key holding procedure and hand over sheet for drug keys although these are still not separated from other master keys. The home is also starting to retain copies of prescriptions although according to staff not all prescriptions have yet been obtained. During case tracking it was established that service users do not always have an up to date medication profile in their care plans. Care plans also need to contain up to date information with regard to ‘as and when’ (PRN) treatments. For example, one service user has two types of creams for a skin condition which include Miconazole Hydrocortizone and white soft paraffin. During interviews staff competently explained which cream they would administer and why however written guidelines must be established in care plans. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 13 A tub of antiseptic cream was found in one service user’s bedroom. This had not been labelled with the date of opening. The cream had been dispensed in February 2004. The cream was not listed on the service users’ MAR sheet. All medications must be either listed on a MAR sheet or be part of the household remedy list. Staff reported that they are aware a pharmacist has been to meet with the manager but is not clear whether the home is now receiving quarterly visits or has a service contract. This will be assessed at the next visit. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon. EVIDENCE: The home has a comprehensive complaints system with timescales for response. A copy is held on individual service user files as is good practice. It is very encouraging to see that staff can also access the complaints system and have raised complaints on behalf of service users which is commendable. There is evidence to demonstrate that the manager deals with complaints in a fair and thorough manner and has a proactive approach to resolving issues. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: A full tour of the premises was undertaken. The home was exceptionally clean and tidy. There is regular maintenance and redecoration; the home employs a handyman for this purpose who was available on the day of the inspection. The communal areas are bright and airy with comfortable and homely furnishings. All bedrooms are decorated and furnished to a high standard and individualised with personal possessions, photographs and stereo equipment. It is pleasing to see that colour schemes, décor and furnishings reflect service users’ individual tastes. The home has a range of aids, adaptations and technical equipment for persons with disabilities. These include assisted baths, portable hoists and bedrails. During interviews staff reported some difficulties in transferring wheelchair users from either their bedrooms into the garden via the patio doors, and also from the lounge via the patio doors. On closer inspection there is a small step and a gap between the step and patio which staff have difficulty in negotiating. Although there is a slightly raised ramp leading from the main egress of the patio and lounge area there is still a small Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 16 gap. This needs to be addressed and a risk assessment carried out in the interim. Another concern identified at this inspection was with regard to the extraneous items stored at the side of the property in front of the garage. These consisted of over twelve tyres and some furniture. This needs to be removed urgently and the handyperson stated that this could be easily rectified by the proprietor via the weekly trips to the Local Authority refuse collection centre. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 The procedures for vetting and recruitment of new staff are good with appropriate checks carried out in order to safeguard service users from abuse. EVIDENCE: There is an outstanding requirement with regard to the home sending staffing proposals to the Commission for Social Care Inspection. The home has been requested to use the staffing guidance recommended by the Department of Health. The home can in fact use any assessment tool they wish but the Department of Health tool is useful in determining dependency profiles of service users. The home must demonstrate how they assess staffing levels to ensure that service users’ needs are met. A personnel file of a newly recruited member of staff was examined. This confirmed that the home has a robust recruitment and selection procedure. Only slight minor improvements are necessary. For example, the Care Homes Regulations 2001 require that employers ensure prospective staff are physically and mentally fit. The home’s application form does contain a question with regard to whether applicants feel they are ‘medically’ and physically fit to work, however a detailed health care questionnaire would provide the home with more information on which to base this judgement. The home must also ensure that copies of job descriptions are held on personnel files to evidence that they have been given to new staff. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 18 Staff personnel files now contain comprehensive individual staff training and development assessment profiles as previously required. It was pleasing to see that newly recruited staff have been registered on an induction programme run by an accredited learning disability awards framework provider. However, through no fault of their own, the home is still experiencing difficulties in trying to ensure that training is completed within the first six weeks and first six months of employment. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Health, safety and welfare of service users is a priority within the home although some improvements are still necessary in order to minimize risk. EVIDENCE: The home still needs to further expand the quality assurance system as previously requested. A full assessment of health and safety standards including maintenance and service checks will be undertaken at the next inspection. An evaluation of progress towards outstanding items was carried out. Improvements are still necessary. For example, the fire alarm system is still not being tested every seven days. There have been no recorded checks since 13 May 2005 and none were undertaken between 8 April 2005 and 22 April 2005. There is evidence to confirm that 3 wheelchairs have been serviced but there remains a further 2 wheelchairs which require servicing according to staff. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 20 Bedrails and wheelchairs health and safety checks have just recently been introduced (on 6 June 2005); further compliance will be evaluated at the next inspection. The kitchen is clean and well organised however, improvements are still necessary with regard to food hygiene practice. For example the home is still not consistently checking and recording cooked food temperatures. There were no checks undertaken between 8 May 2005 and 26 May 2005 this is not acceptable. Foods such as mayonnaise and salad cream are now stored in the refrigerator however there was a selection of opened bottled sauces which were not. These must also be stored in the refrigerator upon opening. The kitchen contained a sack of potatoes which was stored on the floor. If storing food in the kitchen it must be raised off the floor on more appropriate shelving or storage. Other additional items are contained within the Requirements section of this report. Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 2 2 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Conway House Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4, 5 Requirement To review the statement of purpose and service user guide to ensure that all details are included as required by Schedule 1 of the Care Homes Regulations 2001 and National Minimum Standards. (Previous timescale of 1/1/05 is partly met). To ensure that all service users are issued with up to date contract/terms and conditions of residency which include all information contained within Standard 5.2 of the National Minimum Standards for Younger People. (This information was not accessible and could not be assessed.) To produce a service user plan in a format suitable for service users. (Previous timescale of 1/1/05 is partly met). To further develop the care planning system: to include care plans regarding epilepsy and pressure area care. (Previous timescale of 1/1/05 is partly met). To introduce an ‘essential life Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 23 Timescale for action 1/10/05 2. 5 14 1/10/05 3. 6 15(1) 1/10/05 4. 9 13(4)(c) style’ planning format and life story books. (Previous timescale of 1/1/05 is partly met). To ensure that all risk assessments are dated and signed by staff on completion. Any risks which are identified as ‘high’ must be reviewed on a more regular basis. (Previous timescale of 1/10/04 is partly met). To review and expand risk assessments for wheelchair users identifying risk associated with using posture belts, and manufacturers specifications with regard to maintenance checks and servicing. To provide an annual seven day minimum (or shorter breaks if more appropriate) holiday, for service users which is included as part of the basic contract price. (Previous timescale of 1/1/05 is not met). To establish written nutritional care plans for those service users who have increased nutritional needs. To include guidelines for the administration of nutritional supplements. To provide the Commission for Social Care Inspection with an action plan to improve the control and administration of medication in the following areas: 1) To review and expand the medication policy to include all subjects: drug errors controlled drugs, staff training, drug hazard alert notices, medicines taken out of the home etc. To carry out this review in line with best practice guidelines issued by the Royal Pharmaceutical Society. 1/9/05 5. 14 16(2)(n) 1/10/05 6. 17 12(1)(a) 1/9/05 7. 20 13(2) 1/9/05 Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 24 (Previous timescale of 1/6/05 is not met). 2) To establish a written household remedy policy which must be ratified by the G.P. including a list of service users for whom these medicines are suitable. (Previous timescale of 1/6/05 is not met). 3) To ensure that keys to the medicines cabinet are held separate from any other master keys. (Previous timescale of 1/6/05 is not met). 4) To ensure that consent is obtained to medication from each service user and recorded in the care plan (or to acknowledge if this is not possible). (Previous timescale of 1/6/05 is not met). 5) To obtain and retain copies of original prescriptions. (Previous timescale of 1/6/05 is partly met). 6) To ensure more consistent recording of the receipt of medication. (Previous timescale of 1/6/05 is partly met). 7) To ascertain whether the pharmacist has a contract to provide the Home with a service including quarterly visits. (Previous timescale of 1/6/05 could not be assessed). 8) To ensure that all tubs of cream are labelled with the date of opening. 9) To ensure that only creams currently prescribed (or those Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 25 that are included in the homely remedy list) are administered to service users. 10) To ensure that there is an up to date medication profile contained within individual care plans. 11) To ensure there are clear guidelines contained within individual care plans for medication which is administered as and when required (PRN) this includes creams and ointments. 12) To pursue training in the safe handling of medication for staff with an accredited trainer. 1) To either employ a 1/10/05 professional cleaning company or to undertake a replacement of bedroom carpets where stains have not been removed by ordinary cleaning. 2) To improve accessibility for wheelchair users into the garden area from the main lounge and bedrooms by providing more suitable ramps/adaptions. 3) To carry out written risk assessments with regard to access into the garden area for wheelchair users that identify control measures for staff to minimize risks when negotiating step. 4) To remove extraneous items from driveway at rear of premises which include tyres and furniture. 8. 24 23(2)(b) Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 26 9. 30 13(3) 1) To ensure clinical waste bins provided by contractors have locks fitted. (Previous timescale of 1/1/04 is not met). 2) To carry out and display a written risk assessment with regard to the manual sluicing of soiled items. (Previous timescale of 1/6/05 is not met). 1/9/05 10. 33 18(1)(a) 11. 34 19(1)(b) 3) To progress plans to ensure that the remaining seven staff receive infection control training. (Previous timescale of 1/6/05 is partly met). To ensure that a copy of the 1/9/05 Staffing guidance from the Department of Health (DoH) is obtained and the formula applied, taking account of the assessed identified needs of the residents, with the results forwarded to the NCSC for consideration; together with staffing rotas, which clearly identify care hours and ancillary hours, hours spent outside of the Home by service users attending day centres. (Previous timescale of 1/1/04 is not met). To introduce a health care 1/9/05 questionnaire to be completed by new staff to demonstrate that they are physically and mentally fit. To demonstrate that new staff have received a copy of their job description (a copy to be retained on their personnel file as evidence). To ensure that staff receive training in equal opportunities and the Disability Discrimination Act 1995. (Previous timescale of 1/1/04 is partly met). 12. 35 18(1)(a) 1/10/05 Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 27 To ensure that staff receive induction training within the first six weeks of employment which is provided by an accredited Learning Disability Awards Framework provider and meets the Sector Skills Council’s specifications. (Previous timescale of 1/1/05 is partly met). To ensure that staff receive foundation training within the first six months of employment which is provided by an accredited Learning Disability Awards Framework provider and meets the Sector Skills Council’s specifications. (Previous timescale of 1/1/05 is partly met). To review and further develop the quality assurance system – to include stakeholder feedback. (Previous timescale of 1/6/05 is not met). To provide the Commission for Social Care Inspection with an action plan to improve fire safety and health and safety: 1) To ensure that the fire alarm system is tested consistently on a weekly (seven day) basis. (Previous timescale of 1/6/05 is not met). 2) To carry out a written Legionella risk assessment. (Previous timescale of 1/6/05 is not met). 3) To provide written evidence that wheelchairs have been serviced by a recognised contractor. (Previous timescale of 1/6/05 is partly met). Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 28 13. 39 24 1/10/05 14. 42 23(4)(c) 1/9/05 4) To ensure that bedrails on checked on a regular basis with written records maintained. (Previous timescale of 1/6/05 is partly met). 5) To establish frequency of maintenance/service of new adjustable bed. To undertake the following improvements to food hygiene practice: 1) To re-establish the checking and recording of cooked food temperatures. (Previous timescale of 1/6/05 is partly met). 2) To ensure that all high risk foods such as salad cream and mayonnaise is labelled with the date of opening. (Previous timescale of 1/6/05 is not met). 3) To ensure that frozen foods are labelled with the date of freezing. (Previous timescale of 1/6/05 is partly met). 4) To ensure that all foods which require refrigeration following opening (such as sauces) as stored in the fridge. 5) To fit a paper towel dispenser in the kitchen. 6) To ensure more suitable storage for vegetables in the kitchen. To ensure that the business plan is expanded to include a financial plan with details of budgets, predictions and overheads. (Previous timescale of 1/1/05 is not met). 15. 42 13(4)(c) 1/9/05 16. 43 25(1)(d) 1/10/05 Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 2 Good Practice Recommendations To undertake periodic reassessments of service users’ needs, utilizing the assessment tool which has been established for assessing new service users, in order to monitor and measure progress and ensuring needs are continued to be met. To consider the installation of an overhead tracking system in two service users’ bedrooms who require the assistance of a portable hoist. To consider the purchasing of water soluble bags for the washing of any infected soiled items. To consider introducing a procedure for regular health and safety observational checks of wheelchairs. To regularly calibrate the food probe (with boiling water and ice) and to keep written records. 2. 3. 4. 5. 29 30 42 42 Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 30 Commission for Social Care Inspection Mucklow Office Park West Point 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. Extracts may not be used or reproduced without the express permission of CSCI Conway House E55 S4821 Conway House V232194 090605 Stg4.doc Version 1.30 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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