Inspection on 25/04/06 for Crossways Residential Home

This inspection was carried out on 25th April 2006.

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

Crossways Residential Home 19/06/08

Crossways Residential Home 20/06/07

Crossways Residential Home 01/11/05

Crossways Residential Home 08/12/04

Crossways Residential Home 27/05/04

Crossways Residential Home 20/11/03

Crossways Residential Home 24/06/03

Crossways Residential Home 21/08/02

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

CARE HOMES FOR OLDER PEOPLE Crossways Residential Home (All paperwork to Penn) 66 Highgate Road Highgate Walsall West Midlands WS1 3JE Lead Inspector Maggie Bennett Unannounced Inspection 25th April 2006 09:05 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 Crossways Residential Home DS0000020854.V290098.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. Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Crossways Residential Home Address (All paperwork to Penn) 66 Highgate Road Highgate Walsall West Midlands WS1 3JE 01922 646168 01922 646168 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) Obsan Limited Care Home 21 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (21) of places Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Maximum number of service users at any time shall not exceed 21 (Twenty-One). 1st November 2005 Date of last inspection Brief Description of the Service: Crossways Residential Home provides accommodation and personal care for 21 people over the age of 65, 9 of whom may have dementia. The property is currently undergoing extensive refurbishment. When completed, the home will provide accommodation for 23 people in 19 single rooms and 2 double rooms. 12 of the bedrooms will have an en suite toilet. All rooms have a wash hand basin. As well as an increase in bedrooms an additional lounge area, 2 assisted bathrooms plus an assisted shower room have been created. There is an attractive garden to the rear of the property. The range of fee is £317.88 - £346.00 Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one and a half days (11 hours in total). All the Key National Minimum Standards were inspected. Several service users were spoken to during the course of the inspection and discussion took place with three staff members and the Acting Manager of the home. The care plans of a random sample of service users were seen and various other documents were inspected. A tour was made of the building. There have been two Acting Managers in place since June 2005. There is now a third Acting Manager, who took up his post approximately 3 weeks before this inspection. At the last inspection 16 statutory requirements were made. It was found on this occasion that 7 of those requirements have now been met. A further 13 statutory requirements were made following this visit. What the service does well: What has improved since the last inspection? There is evidence that service users have been consulted more often than in the past, particularly with regard to meals and social care activities. This has resulted in more satisfaction among the service users. One person said: “Yes – they (the meals) are better now. We are asked what we want.” Another person said: “If you want something, they’ll do it.” The breakfast menu has improved considerably and there is a much better choice. The Acting Manager intends to similarly improve lunch and tea-time menus. There has also been an improvement in social care activities within the home. The budget for this has been increased and entertainers are now booked on a regular basis. In addition Music and Movement sessions are held and more equipment has been purchased. The physical environment of the home is continuing to improve. 75 of the staff are now trained to at least NVQ2, with several staff having Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 6 completed their NVQ3. Training in Dementia Care has been arranged for staff. It is hoped that there will now be stable management in the home. 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. Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 7 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 Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 8 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): 3 (Standard 6 is not applicable). Although the home has a good system for assessing prospective service users, this is not being utilised and the home has admitted a service user without full knowledge of their needs. Following a proper assessment the home must confirm in writing to the service user that it is able to meet their needs. EVIDENCE: Standard 1 was not inspected on this occasion and is, therefore, not scored. The home is reminded that with the appointment of a new manager both the Statement of Purpose and Service Users’ Guide must be updated. The care plans of two service users, who had been admitted to the home since the last inspection, were seen. In both cases the home had received assessment information from the social worker prior to the person being admitted. In one case, however, the information was so scant that it was inadequate and did not provide the home with the required information. The home had since discovered that the service user had a number of needs of which they were not previously aware and which were proving difficult to meet. The home should not have admitted the service user without a proper assessment. There was no evidence that, following assessment, the home had Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 9 written to the service users confirming that it would be able to meet their needs. There has, therefore, been no improvement in this area since the last inspection. Although Standard 4 was not assessed in detail, it was good to note that appropriate training in dementia care has been arranged for care staff. Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 10 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, 8, 9 and 10. There is a comprehensive care planning system in place. In order for service users’ personal and healthcare needs to be met, they must be given the opportunity for more involvement in their care planning and reviews. The improvement in medication administration has been maintained and service users are protected by the home’s policies and procedures for dealing with medicines. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: The service user plans of 4 people were seen at the inspection. All the plans seen gave details of the person’s individual needs and included a risk assessment. There was evidence that the plans are reviewed by the home on a monthly basis. This was further confirmed in discussion with a member of staff who had recently been reviewing a care plan. At present the care plans are located to the rear of the file and it is suggested that they should be at the front. They would also benefit from an index and division into key areas. Care plans would benefit from more information on social interests, hobbies, cultural and religious needs. There is little evidence of the service users’ involvement Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 11 in the compilation of their care plans. Service users should be asked how they wish their care to be given and this should be recorded, preferably in their own words. The home is advised to ensure that when Social Services reviews are held, a representative of the home is asked to contribute. The Acting Manager stated that recently a social worker had conducted a review in the home with the service user and a relative, but had not asked for any opinion from the staff at the home. As stated at the last inspection, the home must insist on a copy of the notes from such review meetings. Healthcare needs are recorded on the care plans. There must be more information on service users’ dietary needs and their weight. One service user appeared to have lost weight, but there was no record available for this to be checked and there were no measures specifying how this apparent weight loss should be attended to. At present the home has no suitable scales and consequently service users are not being weighed on a regular basis. Two service users are cared for in bed and are visited on a regular basis by District Nurses. Pressure relieving equipment is in place. It was noted that both service users have a daily food and fluid intake chart and care plans contain instructions with regard to moving and handling and checking for pressure areas. The daily notes stated that one service user had a “red area” on their heel, but this could not be cross-referenced to the care plan. Light exercise sessions are now taking place on a daily basis and this was observed during the inspection. The NHS Chiropodist visits regularly and a private chiropodist is also available. An optician and dentist visit regularly. Service users spoken to felt that medical attention was obtained promptly if they had a problem. One said: “I said my eye was sore, the next day the Doctor was here.” Medication policies and procedures have remained unchanged since the last inspection, when they were found to be satisfactory. There are no service users taking charge of their own medication. The home is continuing to measure the temperature of the medication room, which must not exceed 25 degrees. There is a satisfactory system in place for the storage and administration of Controlled Drugs. There is a monitored dosage system in place. Medication is checked and signed in by two members of staff when it arrives at the home. A random sample of the medication and administration record sheets were seen at the inspection and there were no discrepancies. The Acting Manager stated that there were some instances where the G.P. had been prescribing “as required” medication without stating the dose, frequency and dosage interval, including the maximum daily dose. This was creating some confusion for staff. During the inspection the Acting Manager spoke with the G.P. and this issue was resolved, with the G.P. stating that from now on this information would be supplied. The Acting Manager has also requested G.P.s to carry out regular reviews of all the service users’ medication. All those staff who administer medication have taken part in accredited medication training. It was observed during the inspection that service users were asked to take their medication when they were halfway through their meal. Unless specifically directed to do so by the Doctor or Pharmacist, it is Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 12 advised that service users would be more comfortable with taking their medication when they have finished their meal. All the present service users at Crossways have their own single rooms. All personal care giving takes place in private. A payphone is available, but there is also a cordless phone, which service users can take to their room, if they wish. Visitors are able to see the service users in any of the communal rooms or in the service users’ own bedrooms. Service users spoken to felt that their privacy was respected. One said that she could always go to her room when she felt like it and often did in the evening when she enjoyed some “private time”. It was observed during the inspection that service users were treated with dignity and respect, staff always knocking on doors before entering rooms. There was evidence from staff induction records that all new staff receive training in how to treat service users with respect. Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 and 15. There has been a considerable improvement in these areas, particularly with regard to social care activities and meals. The majority of service users feel that they receive good quality food. Service users also feel that they are able to exercise choice and confirm that their relatives and friends can visit whenever they wish. EVIDENCE: It is within the areas of Daily Life and Social Activities that the home has made the greatest improvement in terms of outcomes for service users. Service users spoken to said that they were always able to choose whether or not to join in social activities. There is evidence that the provision of activities has improved since the last inspection. The Registered Persons have increased the budget for this area and several new items of equipment have been purchased. In house activities are now provided by staff on a daily basis and there is a visiting entertainer each month. Music and Movement sessions are held every two weeks. One service user felt that there was still room for improvement in the area of social activities. Despite this view, it is felt that there has been an improvement and it is hoped that this can be built on and that service users will also be given more opportunities for activities outside of the home. Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 14 Service users confirmed that they are able to see their visitors whenever they wish. One person said: “They can come whenever and stay as long as they wish.” A Priest visits each month to administer Holy Communion and other Church representatives visit individual service users. Service users spoken to felt that they were free to make choices and one person gave an example of how she was able to go to her room whenever she wished. It was noted that one service user had the lunchtime meal served in his room, which was his choice. Information on the local Age Concern Advocacy Service is provided in the Service Users’ Guide. The home have written to all service users informing them of their right to access their personal records. The Acting Manager demonstrated a clear view of the service users’ rights to exercise choice and control over their lives. The majority of the service users said that they were happy with the quality of the food provided. One person pointed out that there had been an improvement in this area since the last inspection. She said: “Yes – they (the meals) are better now. We are asked what we want.” Another person said: “If you want something, they’ll do it.” The Acting Manager has already greatly improved the breakfast menu, which now offers considerable choice. He states that he intends to similarly improve the lunchtime and tea-time menus. Staff spoken to agreed that there had been an improvement. Some staff, however, said that at times there was a shortage of cakes for tea and they hoped that this could be remedied. Both the Acting Manager and cooks are aware that a distinct choice must be offered for all meals. Records were seen to verify that fridge and freezer temperatures are taken daily. The cooks confirmed that the temperature of cooked meat was always taken and recorded. It is advised that the temperature of all cooked meats is taken, not just joints. It is further advised that copies of the COSHH information on all products used in the kitchen be available on site (currently this is kept in the office). It is planned that the refurbishment of the kitchen (which is now urgent) will take place within the next few months. Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18. The home has a Complaints Procedure in place and service users feel that their concerns will be listened to and acted upon. There are procedures in place to assist staff to protect the service users. EVIDENCE: There is a Complaints Procedure in place, but this needs to set out the stages, timescales and process. Records are kept of complaints made. No complaints have been received by the home since the last inspection. An anonymous complaint was made to the Commission and this is currently being addressed by the Registered Persons. Written information is provided to service users and their relatives, which informs them of how to refer a complaint to the Commission. Several of the service users spoken to during the inspection said that they would know who to approach if they wanted to make a complaint and they felt that they would be listened to. One person said: “If there was anything wrong I’d tell them – they would rather I did tell them.” Another person said: “Staff listen to you, you can go at any time to the office.” The home have an Adult Protection Procedure and a copy of the local Social Services Procedure. The Acting Manager and majority of the staff have taken part in Adult Protection Training. The Acting Manager needs to familiarise himself with the local Social Services procedure, the Department of Health document “No Secrets” and the Protection of Vulnerable Adults guidance. No allegations have been made against any staff at the home since the last inspection. An allegation made in August 2005 was dealt with very responsibly Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 16 by the Area Manager of the Company and appropriate referrals were made. There is, therefore, evidence that the Responsible Individuals are fully aware of their duties under POVA. Crossways Residential Home DS0000020854.V290098.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, 20, 21, 23, 24, 25 and 26. The physical environment of the home is continuing to improve and Crossways is well on the way to providing a safe and well-maintained environment. There are a number of outstanding issues and it is hoped that these can be resolved speedily. EVIDENCE: Refurbishment and redecoration is continuing at Crossways and this work is almost complete. Service users continue to be happy with the improvements. A programme of routine maintenance was available. The Acting Manager was requested to ascertain whether this contained the correct dates for planned works. A copy of this programme must be forwarded to the Commission. The gardens are attractive and should be ready for the service users to enjoy in the warmer months. Front windows have not yet been repaired or replaced, but it is understood that builders have visited and are providing quotes. The front drive has not yet been satisfactorily repaired, but this work has commenced. It was found that several bedroom doors does not close firmly into the rebates. Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 18 A second lounge will shortly be available. This room is currently stark and inhospitable. It is suggested that service users should be invited to put forward their views as to how this room should be decorated and furnished. New furniture is on order for the second lounge. At the time of the inspection decoration of the hall and landing was commencing. There are sufficient toilets and bathrooms. The ground floor bathroom, however, is currently not in use because of the layout. The assisted toilet is placed next to the bath so that carers can only help service users by standing in the bath. The layout in this room must be re-considered so that there is an accessible bathroom on each floor. All toilets and bathrooms at the front of the property would benefit from blinds to the windows. The first floor bathroom was found to be very hot and staff appeared unable to adjust the heat in this room. It is recommended that the radiator in the ground floor shower room be changed to a smaller size as the door cannot be opened fully at present and this restricts the movement of wheelchairs. It is further recommended that a screen be provided in the ground floor shower room to prevent too much water from going on the floor. Service users spoken to said that they liked their rooms. Several now have their own en suite toilet. The majority of the rooms have been provided with washable floor covering. The Registered Persons have been asked to consult with all service users to ascertain whether they are happy with this floor covering, or whether they would prefer carpets. In several rooms the new floor covering is stained and this must be cleaned. The door to Room 21 was wedged open. If the service user in this room wishes the door to be open, an automatic closure device must be fitted. The pull cord in Room 14 must be relocated as it cannot be reached from the service user’s bed. All rooms are centrally heated and radiators are covered. It was noted that there were portable heaters in two bedrooms and that the heat was not on during the afternoon. The Acting Manager must ensure that the rooms are kept at a suitable temperature so that if they wish, service users are able to use their rooms during the daytime. The laundry is well equipped and there are separate sluice facilities. It is recommended that a sluicing disinfector be provided for the commode pots. Crossways Residential Home DS0000020854.V290098.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, 28, 29 and 30. Staffing levels are adequate to meet the needs of the current service users. They will, however, need to be increased as the number of service users increases. Staff are competent and enthusiastic and have good training opportunities. Some staff files do not contain all the required recruitment documentation, making it impossible to verify that all the necessary checks have been made. New staff receive induction training to enhance their knowledge and skills. EVIDENCE: Rotas were seen during the inspection and these showed at during the daytime there are 3 care staff on duty during the mornings and afternoons. Overnight there are 2 waking members of staff. The Acting Manager’s hours are mostly supernumerary, but he does spend one day a week in a caring capacity. The home employs sufficient domestic staff. Cooks are employed on 7 days a week and they prepare breakfast and lunch. Tea is provided and served by a member of care staff. At present there are 15 service users, 3 of whom need 2 carers to assist them. The home must ensure that when their numbers increase, staffing levels are increased accordingly to meet the service users’ needs. There are no carers under the age of 21. Good progress is being made with NVQ training and currently the home has 75 of its staff trained to Level 2. Several staff already have the NVQ3 qualification. The home has not yet arranged for all of its “bank” staff to receive NVQ training. Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 20 A random sample of staff records were seen and they did not all contain the required documentation. Two contained only one written reference. There was evidence that all had undergone satisfactory Criminal Records Bureau checks. The home is reminded that when checking application forms any breaks in employment must be investigated with the applicant. Staff training records were not available during the inspection. There was, however, evidence that new members of staff receive induction training to Skills for Care specifications. The Acting Manager confirmed that staff receive a minimum of 3 paid days training per year. Service users spoken to during the inspection stated that they were very happy with the care provided. One person said that she “couldn’t wish for better”. Staff were observed to be cheerful and enthusiastic. One member of staff felt that there had been a number of improvements in the home, in terms of both the environment and management. She felt that the staff team as a whole were working well together. Crossways Residential Home DS0000020854.V290098.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, 33, 35 and 38. A new Acting Manager is in place. He is enthusiastic and committed and it is hoped that with experienced staff already in place there will be good, consistent care throughout the home. There is a system in place for measuring people’s views of the home and this needs to be utilised to the full. Service users’ financial interests are safeguarded by secure systems. There is regular staff training and appropriate procedures are in place to safeguard the health, safety and welfare of the service users. EVIDENCE: The Acting Manager has worked at the home for 2 years. The Registered Persons are currently arranging for him to enrol for the Registered Managers Award and NVQ4. In addition to his experience in care he has had some management experience in the past, although not in a care setting. He has taken part in all mandatory training, as well as Adult Protection and Dementia Awareness. The Acting Manager is to take part in the Aset training in Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 22 dementia and is keen to undertake the training in Dementia Care Mapping. He has a job description and there are clear lines of accountability within the home. The staff spoken to showed great confidence in their new manager and some felt that there had already been changes for the better. Although this standard is not met at present, a statutory requirement has not been made as the Registered Persons are clearly taking steps to ensure that the home is adequately managed. The Acting Manager states that he is planning to re-instate Service users meetings, which will be held on a monthly basis. Questionnaires requesting the views of relatives and other visitors are left in the foyer. It is recommended that these are sent to people on a periodic basis, as this should ensure a greater response. It is further recommended that questionnaires are sent to other stakeholders (such as visiting nurses, G.P.s, chiropodists, etc.) The Registered Persons are requested to forward to the Commission a copy of their latest Annual Development Plan. Several of the service users spoken to said that they were listened to and that their views were acted upon (this is particularly evident with the introduction of new menus). The home takes charge of the personal allowances of nine service users. All personal monies are kept securely and individually and appropriate records are kept. The monies of two service users and records were checked at the inspection and there were no discrepancies. The home does not act as agent for any of the current service users. Staff records show that periodic training is held in fire safety, moving and handling, first aid, food hygiene and infection control. Evidence was seen of the regular servicing and maintenance of equipment, including the lift and hoist. Records were also seen to verify the regular testing of water temperatures at outlets accessible to service users. These records must be dated. Certificates verifying the annual servicing of the central heating boiler could not be found, neither could the 5 year electrical wiring certificate. Copies of these must be forwarded to the Commission. Fire safety checks and checks on fire fighting equipment take place at regular intervals. The water supply is tested for legionella on an annual basis. Risk assessments have been carried out for all areas of the home. Accidents, injuries and incidents of illness or communicable disease are recorded and reported to the Commission. It is recommended that the analysis of any hazardous substances used in the home are readily available to the cooks and domestic staff. As part of their induction, all new staff receive induction training on safe working practice topics. Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 23 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X 2 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes. 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 OP3 Regulation 14(1)(d) Requirement The home must ensure that a proper assessment is received prior to admitting a new service user. Following assessment, the Manager must write to the service user, confirming that the home will be able to meet the person’s needs. (Previous timescale of 01/11/05 not met). Service users must be involved in the compilation of their care plans (where possible). Where possible, the service user must be consulted during reviews and requested to sign the review. (Previous timescale of 01/11/05 not met). Following social work reviews, the home must ensure that they obtain a copy of the notes. Care plans must contain more information on service users’ individual nutritional needs and their weights. Suitable scales must be obtained so that all residents’ weights can be monitored. Timescale for action 25/04/06 2. OP3 14(1)(d) 25/04/06 3. 4. OP7 OP7 15(2)(c) 15(2)(c) 31/05/06 31/05/06 5. 6. OP7 OP8 15(2) 17(1)(a) Schedule 3 (o) 16(2)(c) 31/05/06 31/05/06 Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 25 7. OP8 8. OP15 17(1)(a) Schedule 3 (p) 12(1)(a) 9. OP19 23(2) 10. OP19 23(2)(o) 11. OP19 23(2)(b) 12. OP19 23(4) 13. 14. 15. 16. OP19 OP24 OP24 OP22 23(4) 16(2)(c) 23(1)(d) 23(2)(n) Any incidence of pressure areas, their treatment and outcome, must be noted in care plans and reviewed on a continuing basis. The kitchen must be refurbished and this must include the provision of a new cooker. (Previous timescale of 31/12/05 not met). The home must produce a programme of routine maintenance and renewal of the fabric and decoration of the premises. Once the work to the building is completed this must be produced on an annual basis. (Previous timescale of 31/12/05 not met). (A programme has been produced, but this does not appear to contain the correct dates). The front drive must be renewed and made safe. (Previous timescale of 31/12/05 not met). (Work had commenced on the drive at the time of the inspection). Rotting window frames and cracked window panes must be renewed. (Previous timescale of 31/12/05 not met). (It is understood that quotes have been sought for this work). Fire doors must not be wedged open. If, for the convenience of the service user, fire doors are held open, an automatic closure device must be fitted. All fire doors must close firmly into the rebates. Service users must be consulted about the floor covering in their individual rooms. Stained washable floor covering must be cleaned. All emergency call pull cords must be accessible from the service users’ beds. DS0000020854.V290098.R01.S.doc 25/04/06 30/06/06 31/12/05 30/05/06 31/05/06 31/05/06 16/06/05 31/05/06 19/05/06 30/04/06 Crossways Residential Home Version 5.1 Page 26 17. OP21 23(2)(j) 18. 19. 20. OP25 OP25 OP28 23(2)(p) 23(2)(p) 18(1) 21. OP29 Sch 2 Regs 7, 9, 19 13(4)(a) 21. OP38 The layout of the ground floor bathroom must be altered so that staff are able to safely assist service users. The temperature of the first floor bathroom must be capable of being controlled by staff. Service users’ rooms must be warm enough for them to use at all times. Any “bank” staff employed by the home must also take part in NVQ training. (Previous timescale of 30/11/05 not met). Staff files must contain all the documentation required by the Regulations. (Previous timescale of 30/11/05 not met). The Acting Manager must ensure that the dates when water temperatures are taken are recorded. Copies of certificates verifying the annual servicing of the central heating boiler and the 5 year electrical wiring check must be forwarded to the Commission. 30/06/06 12/05/06 25/04/06 30/06/06 31/05/06 31/05/06 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 OP7 Good Practice Recommendations It is recommended that all service user plans should be located at the front of the file. It is further recommended that the plans are provided with an index and divided into key areas. It is recommended that care plans contain more information on social interests, hobbies, cultural and religious needs. The home should ensure that when Social Services review meetings are held in the home, that a representative of DS0000020854.V290098.R01.S.doc Version 5.1 Page 27 2. 3. OP7 OP7 Crossways Residential Home 4. 5. 6. 7. 8. OP8 OP14 OP15 OP15 OP18 9. 10. OP20 OP21 11. 12. 13. OP21 OP26 OP33 the home contributes to the meeting. It is recommended that, unless the Doctor or Pharmacist specify otherwise, service users should be offered their medication after their meal, rather than during it. It is recommended that service users are given increased opportunities to take part in activities outside the home. It is advised that the temperature of all cooked meats is taken. It is advised that copies of the COSHH information on all products used in the kitchen be available on site. It is recommended that the Acting Manager ensures that he is fully conversant with the Local Authority procedures with regard to Adult Protection and that he familiarise himself with his responsibilities as set out in “No Secrets” and the Protection of Vulnerable Adults Guidance. It is recommended that service users be consulted about the decoration and furniture in the second lounge. It is recommended that the radiator in the ground floor shower room be changed to a smaller one, as currently the door cannot open fully and this restricts wheelchair users. It is recommended that a screen by provided in the ground floor shower room. It is recommended that a sluicing disinfector be purchased for the commode pots. It is recommended that questionnaires are sent on a periodic basis to all stakeholders (relatives, other visitors, visiting nurses, G.P.s, chiropodists, etc.). Crossways Residential Home DS0000020854.V290098.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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