Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 27/10/05 for Dawson Road, 5 & Whateley Road

Also see our care home review for Dawson Road, 5 & Whateley Road for more information

This inspection was carried out on 27th October 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a core group of staff who have worked at the home for a long period of time. They are well motivated; participate in the day-to-day operations of the home whilst maintaining a clear sense of direction. Observations revealed positive relationships between staff and service users. Service users have the opportunity to participate in appropriate activities. Staff at the home seek input from other health and social care professionals to assist in meeting individual need. Service user bedrooms are well maintained and personalised. Relatives have been involved in the development of person centred plans.

What has improved since the last inspection?

Some commendable work has been undertaken in recent months to present information about individuals` needs in an accessible and user-friendly way. Person centred plans have been developed for service users. This should have a positive impact on future care planning.A new timetable of activities in partnership with Handsworth College is due to commence soon. The fire evacuation route to the rear of the property was not satisfactory. The hedge in the garden were quite overgrown and had encroached over part of the pathway. The hedge has now been cut back.

What the care home could do better:

Risk assessments must be completed for all areas of identified risk. Each risk assessment should be directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other. A deficit in the design of the bungalows exists, as there is little space for storage. Items such as hoists and weighing scales are therefore stored in hallways. This detracts from providing a homely environment. The Manager must ensure that staff practice is in line with the written care plan. Improvement is required to the systems for the recording and monitoring of fluid intake for some service users where this is an identified need. Satisfactory arrangements need to be put in place for the disposal of medication. A full review of staffing is needed to ensure adequate numbers of competent staff are on duty, the staffing compliment for the home needs to be sufficient to cover for periods of annual leave. Generally, adequate arrangements are in place to ensure that the health, safety and welfare of service users is promoted and protected but it was unclear when repairs to fire doors were scheduled to take place.

CARE HOME ADULTS 18-65 Dawson Road, 5 / Whateley Road Handsworth Birmingham West Midlands B21 9HS Lead Inspector Kerry Coulter Unannounced Inspection 27th October 2005 10:30 Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 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 Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dawson Road, 5 / Whateley Road Address Handsworth Birmingham West Midlands B21 9HS 0121 554 4718/5896 0121 554 4718 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) Milbury Care Services Limited Mr Andrew William George Robson Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 12 beds - Adults with Learning Difficulties and Physical Disability Date of last inspection 10th June 2005 Brief Description of the Service: 5 Dawson and 1 Whateley Road are two six bedded bungalows situated on the corner of Dawson and Whateley Road, off Grove Lane, Handsworth and within walking distance of the Soho Road. They are close to local shopping centres, places of worship and bus routes to the city centre. They are purpose built bungalows providing accommodation and nursing care for 12 adults who have multiple physical and learning disabilities. Each bungalow comprises of a through dining area and lounge, open plan kitchen and utility room, bathroom and six bedrooms. The homes are accessible to each other through a hallway, which joins them. However, this is not accessible to people who have a physical impairment. At the rear of the bungalow is a large secluded garden, which is accessible to all service users. It has lawned areas, trees, shrubs and flowerbeds. Staff are employed by Milbury Care Services and have a multirole, which includes care work, cooking and cleaning. The homes are run as two separate units with two seperate staff teams during the day. At night there is one waking night staff and one sleep-in staff between the two homes. There is one manager for both homes. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted by one inspector over five hours. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from June 2005. Conversations with some of the service users were limited due to their complex needs and limited verbal communication abilities. However, the Inspector met with most of the service users and time was spent observing care practices, interactions and support from staff. A tour of the building and garden was made. Service users care plans, risk assessments and a number of Health and Safety records were inspected. The Inspector had the opportunity to talk with the Organisation’s Service Manager and several care and nursing staff. During this visit the Inspector did not have an opportunity to speak with relatives and other professionals. What the service does well: What has improved since the last inspection? Some commendable work has been undertaken in recent months to present information about individuals’ needs in an accessible and user-friendly way. Person centred plans have been developed for service users. This should have a positive impact on future care planning. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 6 A new timetable of activities in partnership with Handsworth College is due to commence soon. The fire evacuation route to the rear of the property was not satisfactory. The hedge in the garden were quite overgrown and had encroached over part of the pathway. The hedge has now been cut back. 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. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A EVIDENCE: None of these standards were assessed at this visit. At the last inspection in June 2005 a requirement was made for the views of existing service users to be taken into account when admitting new service users into the home, and evidence of how this process is undertaken and its outcome must be available in the home. A prospective new service user has been visiting the home but has not yet moved in. This requirement will therefore be assessed at the next inspection. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 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 the following standard(s): 6 and 9 Care plans are regularly reviewed and provide staff with the information they need to support service users but staff practice does not always reflect the plan. Strategies for managing risks were generally clearly identified but some improvement is required to ensure all risks are assessed. EVIDENCE: The care files for five service users were sampled. Since the last inspection staff have obviously been working hard to complete person centred care plans for each service user. Some good work has been done in involving relatives, staff and where possible the service user in contributing to the plans. Plans include information about individual’s likes and dislikes, things that are important to them and are in a format that includes pictures and photographs. The nursing care plans were also sampled. These had generally been regularly reviewed with evidence of evaluation. Time was spent observing mealtime practice in both bungalows. In one of the bungalows the care plan guidelines for eating were not followed for one service user. The plan stated she needed a special angled spoon but staff fed her with a ‘normal’ straight spoon. This was raised with the nurse on duty who said the care plan needed updating. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 10 A wide range of risk assessments were observed to be available for each individual. Assessments had been recently reviewed and were generally satisfactory. However the assessment for one service user for the risk of developing pressure sores had not been reviewed within the last six months. Unfortunately there was no risk assessment available for one service user who uses bedrails. Bedrail assessments were however available for other individuals. At the last inspection another service user was lacking a bed rail assessment. Some service users have been on holiday. Sampling of records and discussion with staff indicate that risk assessments had not been completed prior to the holidays. These need to be completed to assess areas of possible risk such as the environment, staffing ratios, arrangements for medication storage and disposal of clinical waste. Each risk assessment needs to be directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other. One of the outcomes for completing risk assessments and care plans should be that the finished article is a simple and effective working document, in which essential information can be easily found. There was some evidence of cross referencing but this needs to be expanded. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 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 the following standard(s): 12, 13 and 14 Intergration within the community and pursuit of appropriate activities are integral elements of the ethos of the home. EVIDENCE: Service users have the opportunity to participate in appropriate activities, some based in the home with others in the community. Activity programmes form an integral part of individuals’ care packages. Each individual has a weekly timetable of activities. Service users participate in a variety of activities in the local community including shopping, walks, restaurants, colleges, cinema and pubs. Service users have sensory lighting in their bedrooms appropriate to their individual needs. Service users have their own music systems, TV’s and videos in their bedrooms. TV’s and music systems are also provided in communal areas. On the day of the inspection service users from both bungalows were out at community activities. Discussion with the Nurse in one of the bungalows indicates that a new timetable of activities in partnership with Handsworth College is due to commence soon. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 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 the following standard(s): 18, 19 and 20 Personal support is delivered in accordance with service users preferences and requirements. Health needs are generally appropriately met but recording practice needs to be improved to evidence that all needs are being met. Practices relating to the storage and administration of medication are generally satisfactory with only minor improvement required, this is in part due to recent legislative changes. EVIDENCE: Support is given by staff in a warm and friendly manner, and staff were seen to be polite, considerate, patient and respectful, as appropriate. Care plans include detailed information on the support required for personal care. Each service user has a manual handling assessment that details the type of hoist and size of sling required. This provides staff with the information they need to provide sensitive and flexible personal support to service users. The home provides nursing care and individual plans identify their health needs, this includes the ‘Ok health check’ a type of health action plan. Assessments have been completed to include pressure care, nutrition and risk of dysphasia. Improvements were required at the last inspection on the way that fluid intake is monitored for some service users. Since then new monitoring charts have been introduced. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 13 However sampling of these records for two service users indicates that they are not always having enough fluids. On some occasions only two drinks were recorded daily. Either staff are not recording all drinks offered/given or it is of concern that service users are not being provided with adequate amounts of fluid. The Nurse on duty felt sure that it was an issue of poor recording rather than inadequate fluids being provided. Generally when a service user is unwell the individuals records evidence what action has been taken by staff to include any medical intervention. However some entries did not follow up on the well being of the service user. For example for two service users there were entries regarding sore areas of skin but no follow up about any care given and if the skin had improved. Each service user is registered with a local GP and there was evidence to indicate that regular health checks are arranged with the dentist and optician. Service users records sampled indicated that where appropriate referrals are made to other health professionals including speech and language therapist, occupational therapist, physiotherapist, psychiatrist and the dietician. The arrangements for the administration of medication were sampled in both bungalows. As required at the last inspection topical creams/ointments were observed to be dated on opening. The qualified nurses oversee the administration of medication to the service users. However, sometimes medication is administered by care staff at meal times under the observation of the nurse. At the last inspection it was identified that a clear written policy and procedure is required for this practice, this should also include why this practice is needed as usually it should be the nurse who administers the medication. The Nurse spoken with was unaware if this had yet been completed. ‘As required’ (PRN) protocols are available for service users who have medication prescribed only when needed. It was observed that some protocols conflicted with the care plan for the use of medication to relieve constipation. Some protocols stated that medication was required after three days whilst the care plan stated after four days. This needs to be rectified so that staff are clear about when it should be administered. A recent change in legislation has resulted in pharmacists being unable to receive returned medication from nursing homes unless they have a waste disposal licence. The Nurse spoken with was aware of the new legislation but said that she was not aware of any alternative arrangements being made for medication disposal. This will need to be resolved to ensure the home does not build up excess stocks of medication. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 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 the following standard(s): N/A EVIDENCE: These standards were not assessed and were found to be met at the last inspection in June 2005. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 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 the following standard(s): 24, 26, 27, 29 and 30 The environment is generally comfortable and homely but in some rooms and hallways this is spoilt by clutter and equipment due to the lack of storage space. EVIDENCE: The premises are in keeping with the local community. Each of the homes is accessible to the six service users living in each home. The corridor joining the two homes is not accessible to service users but is accessible to staff as required. The home was clean and free from offensive odours. Generally the home is decorated and maintained to a high standard. Furnishings, fittings, adaptations and equipment are as domestic, unobtrusive and ordinary as is compatible with fulfilling their purpose. As previously required repairs at one kitchen sink have been completed where the sealant was quite mouldy and required removing and re-sealing. However the sealing strip is starting to peel away from the wall and will again require attention in the near future. A deficit in the design of the bungalows exists, as there is little space for storage. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 16 Items such as hoists and weighing scales are therefore stored in hallways. As at the last inspection the contents of bathrooms highlighted the problem, they observed to contain boxes of nutritional drink, plastic syringes, a moulded chair, part of a bed, a decorating table, hoists, boxes of pads and a vacuum. The organisation must ensure that this is resolved, consideration could be given to providing secure storage in the garden area. Discussion with the Service Manager indicates that Milbury are aware of the storage problem but as they do not own the property they are limited by what they can do to resolve the issue. The Service Manager stated that a meeting with the landlords of the property were was arranged and this issue would be on the agenda. Service users bedrooms were personalised and contained many appropriate personal effects and equipment. Where appropriate service users bedrooms reflected their cultural background. Service users bedrooms contain a chest of drawers, chair, bed appropriate to their individual needs, wardrobe, bedside table, wash hand basin, space for service users possessions, two double sockets and sensory lighting equipment. A range of sensory lighting equipment is provided in each bedroom, according to service users individual tastes and needs. Each of the bungalows has a bathroom, which service users can access supported by staff. Assisted bathing facilities and shower trolleys are provided in the bathrooms. However bathrooms are not pleasant in appearance due to the clutter of all the items stored there. At previous inspections staff informed the inspector that the baths are not suitable for the needs of the current service users and therefore only the shower trolley is used. Discussion with one of the Nurses indicates that this issue has now been resolved and that quotes are now being obtained for new baths to be installed. Where appropriate service users have adjustable beds and pressure relief mattresses. Sensory lighting equipment, mobiles and mirrors are provided in service users bedrooms where appropriate. The home has a variety of hoists, sliding sheets, shower trolleys and other specialist equipment. One of the two hoists in Whateley Road is awaiting repair. A member of staff said that this had been the case for some time and that only having one working hoist was not practical. An immediate requirement was made for the CSCI to be notified of the planned date for repair. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 Staffing levels require review to ensure that the needs of all service users continue to be met. EVIDENCE: The home has a core group of staff who have worked at the home for a long period of time. They are well motivated; participate in the day-to-day operations of the home whilst maintaining a clear sense of direction. During the day the homes are staffed as two separate houses. There is one registered care manager for the two homes who is additional to the staffing numbers on the rota. At night the home is staffed as one home by one qualified nurse, a support worker and a support worker sleeping – in. At the time of the inspection the Manager was on annual leave. Another member of staff was also on annual leave that week, and one staff was on maternity leave. Discussion with staff indicates that the home tries not to use agency staff to cover staffing deficits unless absolutely necessary. Observation of the rota for 24th October to 30th October showed that there were four shifts where only one nurse was on duty to cover both bungalows. It has previously been the practice for a Nurse to be on duty in each bungalow during the day. With only one Nurse on duty this means they would have to leave their designated bungalow to administer medication and carry out other nursing tasks during their shift. This has the potential to leave one bungalow short of staff during that period. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 18 Most service users require two staff to assist with hoisting. Given that often there are three staff on duty in a bungalow, to include the Nurse then it is not clear that the current staffing levels are adequate. A full review of staffing is needed to ensure adequate numbers of competent staff are on duty, the staffing compliment for the home needs to be sufficient to cover for periods of annual leave. It was not possible to sample the supervision and training records for staff. As neither the Manager or Deputy Manager were on duty staff did not have access to these records. Previous requirements made will therefore be assessed at the next inspection. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 Generally, adequate arrangements are in place to ensure that the health, safety and welfare of service users is promoted and protected but it was unclear when repairs to fire doors were scheduled to take place. EVIDENCE: The fire safety records were examined and all tests, checks, servicing of equipment, drills had been completed or scheduled as appropriate. Staff had identified that some of the fire doors in Whateley Road were not closing properly. This had been reported to the maintenance department on 24th October but staff did not know when the repairs would take place. Given that service users have a physical disability that may impact on the speed in which the home can be evacuated in the event of a fire it is essential that the fire doors are effective. An immediate requirement was made for the doors to be repaired. At the last inspection the fire evacuation route to the rear of the property was not satisfactory. The hedge in the garden were quite overgrown and had encroached over part of the pathway. The hedge has now been cut back. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 20 Staff test the fridge and freezer temperatures regularly to make sure that food is being stored at the correct temperature. Staff test water temperatures weekly. Records of these showed that these are safe. One service users bedroom had a trailing electricity cable blocking access to the sink, this was addressed by the Nurse when brought to his attention. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 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 X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 2 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dawson Road, 5 / Whateley Road Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000024836.V262334.R01.S.doc Version 5.0 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 YA2 Regulation 12(3) Requirement Timescale for action 30/11/05 2 3 YA6 YA9 15 12(1) & 13(4) 4 YA9 2(1) & 13(4) The views of existing service users must be taken into account when admitting new service users into the home. Evidence of how this process was undertaken and its outcome must be available in the home. (Previous requirement from June 2005, not assessed at this inspection and carried forward to next inspection) The Manager must ensure that 15/11/05 staff practice is in line with the written care plan. The Manager must ensure all 30/11/05 risks to service users are identified and a risk assessment completed and reviewed at least six monthly. To include: 1. The use of bed rails. (Outstanding from 17/6/05) 2. Risk of pressure sores. (Requires review for one service user) 3. Service user holidays. Each risk assessment should be 30/12/05 directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa. DS0000024836.V262334.R01.S.doc Version 5.0 Dawson Road, 5 / Whateley Road Page 23 5 YA19 12(1) 6 YA19 12(1) 7 YA20 13(2) Improvement is required to the systems for the recording and monitoring of fluid intake for some service users where this is an identified need. (Outstanding requirement from inspection in June 2005). The manager must ensure that staff complete daily records detailing well-being, any care given and response to care so that staff can effectively monitor the health of service users. (Outstanding requirement from inspection in June 2005). Administration of medication to the service users by care staff- A clear written policy and procedure is required for this practice, this should also include why this practice is needed as usually it should be the nurse who administers the medication. The draft policy should be forwarded to the CSCI Pharmacy Inspector for approval. (Outstanding requirement from inspection in June 2005). Satisfactory arrangements need to be put in place for the disposal of medication. The Manager must ensure that written protocols for ‘as required’ medication do not conflict with the guidance in the care plan. Adequate space for the storage of equipment must be provided. The CSCI must be notified on how this is intended to be achieved. Ensure the bathrooms are free from un-necessary clutter.(Outstanding requirement from inspection in June 2005). The Manager must notify the CSCI of the intended date for the provision of baths that are DS0000024836.V262334.R01.S.doc 30/11/05 30/11/05 30/12/05 8 9 YA20 YA20 13(2) 13(2) 30/12/05 30/11/05 10 YA24 23 (2) (d,l) 30/12/05 11 YA27 23 (2) (d,l) 23(2)(n) 30/11/05 12 YA29 30/11/05 Dawson Road, 5 / Whateley Road Version 5.0 Page 24 accessible to service users. 13 YA29 23(2)(n) The CSCI must be notified of the 31/10/05 planned date for the repair of the out of use hoist in Whateley Road. A full review of staffing is needed 30/11/05 to ensure adequate numbers of competent staff are on duty, the staffing compliment for the home needs to be sufficient to cover for periods of annual leave. Ensure all self closing fire doors 31/10/05 work satisfactory. (Manger has informed CSCI that this has been completed since the inspection) 14 YA33 18(1)(a) 15 YA42 13(4) 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 YA24 Good Practice Recommendations Consideration should be given to providing secure storage in the garden area. Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Dawson Road, 5 / Whateley Road DS0000024836.V262334.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!