Inspection on 25/07/06 for Glebelands

This inspection was carried out on 25th July 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebelands 28/05/08

Glebelands 05/06/07

Glebelands 09/02/06

Glebelands 21/09/05

Glebelands 02/02/05

Glebelands 17/08/04

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

CARE HOME ADULTS 18-65 Glebelands Kempton Way Off Heath Farm Road Norton, Stourbridge West Midlands DY8 3AZ Lead Inspector Jayne Fisher Unannounced Inspection 25th July 2006 09:00 Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 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 Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 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. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebelands Address Kempton Way Off Heath Farm Road Norton, Stourbridge West Midlands DY8 3AZ 01384 813590 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) Chadd Housing Association Care Home 18 Category(ies) of Learning disability (17), Learning disability over registration, with number 65 years of age (1) of places Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Three services users in the category Learning Disability (LD) may also have a physical disability (PD). One service user in the category of learning disability (LD) may also have a mental disorder (MD). 9 February 2006 Date of last inspection Brief Description of the Service: Glebelands is an 18 bedded care establishment which is provided through a partnership of the Churches Housing Association of Dudley District (CHADD) and Dudley Metropolitan Borough Council (MBC) Social Services Department. The property is owned and managed by CHADD who are the Registered Providers. Dudley MBC provides staffing to support service users. The Home was originally built in 1970 but was totally refurbished in 2000. The unit is a two storey property which is separated into four flats: two with five beds and two with four beds. All bedrooms are single occupancy. Each flat has its own laundry, lounge and dining room with adjoining kitchen and an additional area for making snacks. There are bathing and toilet facilities on both floors which include level access showers. There is 1 assisted bath on the ground floor in flat 2. Each flat has its own private entrance with a secure entry phone system. There is a large meeting room on the ground floor which also acts as an activities room for service users with a television and pool table. A shaft lift and stairway give access to both floors There is a garden with an enclosed courtyard. Glebelands has a large car park to the side of the premises. The Home is situated in a residential area of Stourbridge, the town centre being within easy access. The Home provides care for 18 adults who have a learning disability, one of whom is over the age of 65 years. A statement of purpose and service user guide are available to inform residents of their entitlements. Information regarding fee levels were provided on 23 June 2006 which are between £464.56 and £952.07 per week. There are additional charges for toiletries and hairdressing. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days between 09:00 a.m. and 18:30 p.m. hours on the first day, and 09.00 and 14:00 hours on the second day. 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: interviews with the acting manager and eleven staff. Thirteen residents completed questionnaires all with the aid of staff. Where possible, responses were discussed with residents. Four relatives completed comment cards and one General Practitioner. All service users were at home during varying stages of the inspection. Some were happy to speak with the inspector and either gave consent, or showed the inspector their bedrooms. Formal interviews were not always appropriate and the inspector chatted formally and informally to twelve residents. Six residents’ care was case tracked by reading and assessing care documents, observing interactions and by talking to staff and chatting to residents. One meal time was observed. A tour of the premises was undertaken to assess the standard of the environment. Staff personnel files were accessed and a sample of maintenance and service records were examined. Other documentation was reviewed including a pre-inspection questionnaire completed by the manager. Since the last inspection the Registered manager has left the home. An acting manager has been appointed who previously worked at the home as a practice supervisor. What the service does well: Staff continue to encourage residents to maintain and develop social, emotional and independent living skills. For example, some residents travel independently, help with food shopping, food preparation and take responsibility for cooking their own evening meals. Some residents are due to move to alternative accommodation as they want to live more independently and staff are helping with this process. During interviews residents stated that they felt safe and liked living at their home. Residents’ health and wellbeing is fully promoted by ensuring there are nutritious, varied and well balanced meals. Staff continue to support residents to access health care facilities and there is good monitoring so that any potential complications are quickly identified. The premises is furnished to a high standard thereby providing residents with a comfortable and homely place to live. All communal areas are light and airy with modern furniture. Bedrooms are decorated and furnished according to Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 6 resident’s wishes. They contain lots of personal possessions such as televisions, hi-fi centres and videos. There is a complaints procedure so that residents can make their concerns known; during interviews staff knew how to support residents if they wished to complain. All staff who were interviewed stated that they felt supported by management and could seek advice when needed. What has improved since the last inspection? What they could do better: The main weaknesses of this service are with regard to staffing shortages as a result of continued vacancies and high percentages of sick leave. In addition to this there are insufficient staff on duty to meet all residents’ needs and preferences on a daily basis with regard to providing stimulating activities and outings, particularly for those residents who require more support. Part of the home is staffed to a bare minimum and on occasions due to sick leave, the number of staff on duty has fallen to below the number usually required. There is high usage of agency staff which can impact upon the consistency of care and support provided to residents. In addition, staff are not receiving the required training to support residents, training is being planned but on occasion has had to be cancelled in order to meet staffing levels. The poor progress towards meeting outstanding requirements made at previous inspections could be attributed to the lack of sufficient staff, for example poor care planning, risk management, record keeping, and arrangements for medication. Staff are not receiving regular supervision sessions with their managers. There is no quality assurance system for Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 7 residents to be able to participate in the development of the service. There were two serious concerns identified at this visit which included inadequate recruitment and selection procedures which as a result do not offer adequate protection to residents. The second concern was related to a health and safety issue and the premises. Immediate action is required to address these issues. 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. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 8 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 Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 9 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): 2 The overall outcome for this group of standards is judged to be good. There is a procedure to ensure that new residents are admitted following a comprehensive assessment. EVIDENCE: There are no vacancies at the Glebelands. The last resident was admitted in 2004. An assessment tool examined at that time confirmed that all of the topics required by the National Minimum Standards had been included and assessed. The previous manager had failed to obtain a copy of the care plan and assessment carried out by the placing officer and this was discussed as a requirement at that time. The resident has now been living at the home for over eighteen months. During interviews she stated that “I like living here” and had made friends with other residents. As examined at previous visits there is a range of information for prospective residents to inform them of the services provided at the Glebelands including a statement of purpose and service user guide. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 10 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, 7 and 9 The overall outcome for this group of standards is judged to be poor. Care plans and risk assessments require expansion, updating and review as they do not cover all aspects of personal and social, and health care; this has the potential to place service users at risk. EVIDENCE: A sample of care plans and risk assessments were examined. As noted at previous visits, these are inadequate. The manager acknowledges that these are areas where significant improvement is needed. It was reassuring to see that plans were already underway to improve systems and these were being discussed with staff at a meeting held on the first day of the inspection visit. Over the past few years attempts have been made at improving care planning and risk assessments but once again, any improvements made have not been sustained and standards have deteriorated. Care plans do not cover all aspects of needs and support. Care plans introduced in 2003 have not been reviewed and updated accordingly to reflect changes in residents’ dependency levels and needs. For example, there were no care plans in place for epilepsy, continence management, nutrition or mobility. One resident has a care plan in Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 11 place for tissue viability but this still requires updating to describe the current methods employed for pressure relief including equipment which is being used. During interviews one member of staff failed to demonstrate suitable knowledge regarding what pressure relieving equipment was in place for the resident. Some residents have entered into personal relationships and a ‘social activity’ programme has been established, however there is no care plan in place to provide guidelines for staff in supporting them in their relationship (although reassuringly staff have received training). One resident had recently gone missing but the care plan had not been updated to reflect any extra support that had been necessary regarding travel training. Residents do not have comprehensive care plans in place with regard to challenging behaviour (see further comment in standard 23). Whilst there are behaviour management guidelines in place, these do not constitute care plans. The whole system for care planning and recording is confusing by its complexity and time consuming to complete. For example there is a care plan folder in the main office, there are folders held on flats with copies of some care plans and risk assessments and daily reports, this is in addition to another central folder held in the main office completed by senior staff and which includes another daily reporting system, health checks and outcomes from appointments, and behavioural management guidelines for some residents. Disappointingly the same behavioural management guidelines for one resident could not be located by staff working on the flat where this resident lives and where this information is more needed. During interviews staff were not familiar with the content of care plans and one person admitted that they had not read the care plans. Attempts have previously been made at person centred planning but improvements have not continued. Booklets remain incomplete. As discussed with the manager, differing person centred planning styles need to be considered to meet the varying needs of residents. Training is recommended. Two residents commented in questionnaires that that did not have a care plan. Care plans contain basic information regarding communication. The manager reported that communication passports are going to being devised. There are basic care plans in place with regard to how residents receive support to manage their finances. However, these have not been updated since 2003 and do not reflect current needs. For example, one service user is currently being offered extra support for budgeting as observed during the visit which is not reflected in his care plan. Risk assessments as with care plans have not been reviewed or up dated since they were established in 2004. Not all risks have been identified or assessed. For example, there were no risk assessments in place with regard to challenging behaviour, incontinence, bathing and water temperatures, mobility etc. Risk assessments which are in place are basic in content and in some cases are scored inaccurately. For example, one person was said to be low Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 12 risk with regard to personal relationships which is inconsistent with previous history. A risk assessment in place with regard to the use of a wheelchair did not assess all of the risks associated with using this equipment including those identified in previous medical device alert notices (including posture belts and seating accessories). A risk assessment in place for one resident with regard to pressure area care gave no guidelines for staff with regard as to how to identify a potential pressure sore and failed to contain information regarding all of the pressure relieving equipment in place. One person had recently got lost when out in the community but the risk assessment with regard to use of public transport had not been updated and was still scored as ‘low’ risk with insufficient guidelines and control measures in place. Other issues discussed during inspection of these standards are included in the Requirements section of this report, including the need to ensure residents’ meetings are held more frequently and recorded (some flats are having regular meetings, others are not as confirmed by interviews with residents). Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 13 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, 15, 16 and 17 The overall outcome for this group of standards is judged to be adequate. The majority of residents enjoy a stimulating and varied lifestyle however, those who residents have increased dependency need to be offered more opportunities to participate in stimulating activities in the home and community. Staff support residents to maintain important relationships with friends and families. Residents are provided with a varied and well balanced diet. EVIDENCE: All residents (apart from two) attend a variety of day care provision including attendance at colleges, day centres and work placements. Where possible residents are encouraged to travel independently and were observed undertaking a number of independent living skills tasks such as going shopping, helping prepare meals and laying tables for lunch. A number of residents chatted about their favourite activities and leisure pursuits. One person stated he had enjoyed his day at work and was going to cook ‘burgers’ for tea. Since the last visit two computers have been purchased for the main Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 14 lounge and residents have assisted in growing two vegetable patches. The majority of residents who completed questionnaires felt that there were sufficient activities available, however a couple of residents felt that they would like more opportunities for social interaction which they repeated during interviews. There are some residents at Glebelands who have decreased dependency and therefore require increased support which at present staff struggle to provide because of a lack of sufficient staffing levels. For example, one resident was observed to ask a senior support worker if she could go shopping, the member of staff said that she would find someone to go with her, but unfortunately this request could not be accommodated. On the second day of the inspection, three residents had to stay at home in flat four because there was only one member of staff on duty. During interviews a number of staff expressed concern that they felt there were not enough staff of duty to provide sufficient support for residents in this flat. Whilst it was reassuring to see that the manager is trying to make improvements and staff are now appointed and specifically deployed to arrange activities, unfortunately no extra hours are allocated and staff have to undertake this work as well as their support tasks. Case tracking was difficult due to poor record keeping with regard to weekly activity programmes and activity record sheets. Some activity programmes are not fully completed on all days and those activities which are identified are questionable. For example, the only activity identified on behalf of one resident on a Sunday is that she is to receive money for the forthcoming week. One resident’s activities were case tracked during a four week period, according to the activity record sheet these only consisted of going to the doctor, watching a video and visiting her family. Examination of the daily reports revealed that she had also gone on three other outings. However, overall this is not acceptable. Interviews with residents and staff plus examination of documents confirmed that there are ample opportunities for residents to enjoy relationships with families and friends with support offered where necessary. One resident confirmed that she still enjoyed visiting a previous resident who now lives elsewhere and that staff support her in doing so. Daily routines are flexible and respect residents’ rights. There are a couple of exceptions. During interviews a couple of residents stated that staff failed to knock on their front doors when entering the flat despite notices displayed to as a reminder. As observed during the visit, staff working on other flats frequently entered other flats without knocking. The telephone remains in the main lounge and residents again complained that it should be moved to a more private area. This remains an outstanding requirement. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 15 One meal time was observed in one of the flats which was relaxed and unhurried. Residents were seen to have different food options. As observed on the first day of the visit residents are involved in food shopping and preparing meals. One flat has a daily task allocation list and this includes identifying which resident will cook the evening meal. During interviews two residents who were present in the flat said that they enjoyed this activity. They knew which resident was cooking their evening meal and what they were having for dinner. Residents confirmed that they could choose want they wanted to eat. There was a comprehensive list of likes and dislikes with regard to one resident’s preferred foods in one of the flats. A separate menu plan had been devised because according to staff the resident did not like a lot of the foods that other residents enjoyed which is commendable. There are a couple of items which require improvement as detailed in the Requirements section of this report for example with regard to nutritional assessment and screening. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 16 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 The overall outcome for this group of standards is judged to be adequate. The health needs of residents are well met with evidence of good multidisciplinary working on a regular basis. The arrangements for control and administration of medication needs improvement as at present systems have the potential to place residents at risk. EVIDENCE: All residents who completed questionnaires stated that they felt well cared for by staff. There were two exceptions where residents had stated ‘only sometimes’. During interviews with the residents, one commented that he wasn’t happy living at the home because he wanted more independence. It was pleasing to see that a move is imminent. Another resident stated that they wanted to move because they would receive more money but that they would miss the staff and would frequently return to visit. As previously required, care plans need to be established with regard to how residents are to be supported with personal care, including getting up and going to bed times, bath times and opposite and same gender care. All residents at the Glebelands are mobile although some require aids and equipment to assist with walking. There is a small range of technical aids including a bath hoist in one of the flats. All relatives who completed Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 17 comment cards stated that they were satisfied with the overall care provided by staff. There was ample evidence to confirm that the health needs of residents are monitored by staff and access to appropriate treatment is sought when necessary. For example, there was a good system for recording routine health checks required through out the year. These demonstrated that residents receive regular appointments with dentists, doctors, psychiatrists, chiropodists and ophthalmologists. Specialists are accessed as and when required. For example, the intensive support team (psychologists) are involved with a number of residents in drawing up management behavioural guidelines and giving advice to staff. Another resident had recently been seen by cerebral palsy specialists who had visited to give advice regarding exercises and were to return. There are only two residents on PRN ‘as and when required’ antipsychotic medication. Examination of medication administration record (MAR) sheets reveals that this is not routinely administered. A General Practitioner (G.P.) who completed a comment card stated that staff worked in partnership and communicated well. There are only a couple of minor improvements needed. Residents in all flats are still not receiving regular monthly weight checks. Care plans need to be established with regard to procedures to supplement annual attendance at well person clinics, where possible a programme of education with regard to self examination should be considered or guidance for staff with regard to observing any physical abnormalities and action to take. The priority for screening for health care booklets remain incomplete. These should either be fully completed or abandoned and a new system implemented with regard to health action plans. There were problems identified at previous inspections with regard to medication and a number of requirements were made. Some of these have received appropriate action, for example, there are detailed guidelines now in place with regard to the administration of any household remedies. However, a large number of requirements remain unmet. Examination of systems confirm that arrangements for the control and administration of medication remain unsatisfactory for example:- over a three week cycle there were fifty gaps counted in the MAR sheets where there was no staff initial or letter code to confirm whether or not the medication had been administered. A sample were cross referenced with the corresponding monitored dosage system (MDS) pack and found that the drugs had been administered. However, creams, ointments, inhalers or sprays could not be checked in this manner. - one resident should be receiving regular diabetic urine testing which is not being undertaken according MAR sheet records. - staff had handwritten instructions on MAR sheets but other than simply identifying the name of the drug, there were no instructions with regard to Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 18 dosage, strength, form or frequency. - one resident according to the computerized MAR sheet is supposed to be administered Paracetmol two tablets, four times daily, but staff are not following these instructions. - staff are secondary dispensing medication on behalf of one resident who goes on social leave. There are no written procedures or systems for checking and monitoring that correct dosages are dispensed. Secondary dispensing is not usually acceptable practice and must be discussed with the pharmacist with written procedures and training for staff if this is approved. - as opposed to commencing a new MAR sheet, staff had entered another drug onto the same MAR sheet record as another and different type of medicine. - night staff are still responsible for administration of some medication although they have received no training. The manager has been trying to access some training – advice was given to the new guidance issued by the Commission for Social Care Inspection and which is available in the Internet. Other items discussed during this inspection of medication are contained on the Requirements section of the report and include a system for assessing the competency of staff who are responsible for administration of medication which must be given priority. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 19 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): 22 and 23 The overall outcome for this group of standards is judged to be adequate. There is a complaints system which ensures that users’ views are listened to and acted upon. There are written procedures in place to safeguard service users from abuse although staff require training to ensure that they are familiar with these policies, procedures and principles. EVIDENCE: During interviews residents confirmed that they knew who to complain to if they were unhappy. For example, one resident stated I would tell Lynda (the manager). Staff also gave good examples during interviews as to how they would support residents in making their concerns known. There have been no complaints received by the CSCI regarding the home. Examination of the complaints log revealed that no complaints had been received by the home. Two out of three relatives who completed comment cards stated they were aware of the home’s complaint procedure. Only four out of twenty nine staff have received training in vulnerable adult abuse awareness. During interviews another member of staff confirmed that they had recently undergone training. It was reassuring to see that future training is planned (although some had been cancelled because staff could not be released due to insufficient staff to cover shifts). During interviews not all staff were able to give adequate responses to how they would deal with potential incidents of abuse and some staff were unable to explain the principles of Whistle Blowing. In May 2006 an incident had occurred between residents which staff had failed to recognise as abusive and had accordingly not followed the correct vulnerable adult abuse procedures. This received appropriate action by the manager following discussion with the Inspector. It Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 20 was reported to the vulnerable adult abuse team who undertook a visit and concluded no further action was needed. Care plans are basic with regard to challenging behaviour and in some cases do not include all types of behaviours which are exhibited and guidelines for staff in managing them. During interviews staff were generally aware of the content of management behavioural guidelines which had been drawn up (although couldn’t always locate them in the care plan folder). This is concerning given the amount of agency staff which are employed. During interviews staff gave examples of how one residents’ behaviour is managed which includes escorting the resident to their own bedroom. Staff gave varying times as to how long they would leave the resident in his bedroom and one staff member stated that they would ask him to leave the dining table even if he was in the middle of his meal. According to staff the resident enjoyed spending time alone in his bedroom. Care plans only gave basic information. It is unclear as to who devised this strategy or upon what guidance from specialists. This type of behaviour management which equates to seclusion and physical intervention needs to be formally agreed within a multi-disciplinary team including the resident. On inspection there continues to be good systems in place to manage residents’ finances. A sample of monies balanced accurately with records being maintained. There is regular auditing and balancing by the administrator and senior staff. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 21 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 and 30 The overall outcome for this group of standards is judged to be adequate. Service users have an attractive and comfortable home but some aspects need improvement to ensure that standards continue to be maintained. EVIDENCE: A tour of the premises was undertaken and residents’ bedrooms were entered with their consent. 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. During interviews one resident confirmed that she had chosen her own colour scheme for her bedroom and liked it. Unfortunately, stained carpets and furniture in one of the flats has still not been replaced. There were found to be a number of carpets which were now stained and there was also stained and worn furniture in another flat. There was a serious concern identified at this visit. On a tour of the environment on the first day of the visit it was noted that the tiles were missing from the upper walls on the outside of the premises. These had Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 22 become dislodged in areas and had broken and fallen onto the surrounding perimeter which included a pathway used by residents, staff and visitors to access the rear part of the building. On the next day of the visit the manager stated that night staff had reported that a further tile had become dislodged and was broken on the floor. An Immediate Requirement was issued to address the situation. Since the last inspection building work has been completed on four bungalows which have been built in the grounds of the home to accommodate people who are living in supported living projects. The building of these premises was agreed by the CSCI as they did not impact upon the residents’ communal space (garden area). However, the plans submitted included a fenced area to provide privacy and security for the residents at the Glebelands. No fence has been installed. As a result some of the bungalows overlook three residents’ bedrooms. Whilst net curtains are in place this does represent an issue of privacy and the new manager was unsure as to what consultation had taken place with regard to whether residents were happy with this situation. A consultation must therefore be undertaken. In addition there is also an issue of security. There are lockable gates fitted to the entrance of the bungalows and rear of the home. The manager has given a spare key to staff at the bungalows for access in an emergency. As discussed, security arrangements must be assessed given the new bungalows close proximity to the home and a written risk assessment completed. All parts of the home were seen to be clean and hygienic. There was one bedroom which had a slight malodour. The manager stated that she was already aware of this issue and was reviewing infection control systems. Staff (and residents) were seen to be wearing appropriate protective clothing when preparing food, although one staff member was seen wearing latex gloves carrying money into the main office which is not good practice. There were still plastic jugs (unlabelled) found in one of the bathrooms. There was no protective clothing found in the laundry on flat two. The ironing board was also stained and torn and should not be stored in this area. The laundering of mop heads were not seen on any cleaning schedules although these were colour coded and dried inverted. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 23 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): 32, 33, 34, 35 and 36 The overall outcome for this group of standards is judged to be poor. Standards with regard to the number of staff who are NVQ qualified and who have received the required, specialist and induction and foundation training remain poor. Staffing levels need review as at present there is insufficient staff to meet all of service users’ needs. Staffing shortages as a result of vacancies and high levels of sick leave together with the use of agency staff have impacted upon the consistency of support provided to residents. Service users are not protected by the home’s recruitment and selection procedures. EVIDENCE: The home employs twenty-nine support workers, ten of whom are qualified to NVQ II or above. This does not meet the National Minimum Standards. The manager states that three staff are currently undertaking this training and two further staff have been enrolled. Specialist training remains outstanding in a number of area although eleven staff have training certificates to demonstrate they have recently received training in ‘positive approaches’ (managing challenging behaviour). Staff have not received training in diabetes or cerebral palsy awareness. Thirteen staff undertook training in epilepsy awareness in 2004. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 24 The home continues to experience staffing shortages. For example the manager estimates that currently 40 of the staff team are off sick. There are three vacancies and recruitment and selection is on-going. During interviews residents commented on the use of agency staff; one resident stated “I don’t like agency staff”. A G.P. who completed a comment card stated that there wasn’t always a senior member of staff to confer with. A relative also commented about the difficulties with staff sickness. Examination of the duty rota confirms that there are five support staff on duty per shift plus one senior support worker. However, this staffing level is not always being maintained. For example, during the previous week there were three occasions when only four support workers were on duty. As discussed with the manager the CSCI must be notified when staffing levels are reduced in this way. At least once a week the manager is not supernumerary having to cover for a senior support worker. Issues with staffing has impacted upon a number of areas including the frequency of structured staff supervision, training and residents’ activities and outings as already mentioned in this report. At present there is only one support worker allocated to flat four, however interviews with the manager and staff confirmed that they felt this was insufficient given the increased dependency of the five residents. This was evidenced during observations and examination of documentation. A review of staffing levels and residents’ dependency levels must be undertaken. Recruitment and selection procedures are not robust. The required preemployment checks and supervision of new staff by the previous manager was not undertaken. For example, one member of staff commenced employment in May 2006. There was no written explanation for the gap in employment history between 2003 and 2005. The staff member had declared on their application form that they had commenced employment with a previous employer on 15 February 2005 which did not correlate with the date given by the former employer. There was no copy of a recent photograph held on the file. There was no copy of a criminal record bureau disclosure (CRB) check on the premises (although other staff files held originals and photo-copies of CRBs). There is correspondence from the Human Resources Department of Dudley M.B.C. to the former manager stating that a CRB check (including the disclosure number) had been received on 21 June 2006 was clear. There is no indication as to the outcome of the Protection of Vulnerable Adult (POVA) check. There is no evidence on the file that a POVAFirst check had been undertaken. Upon request the manager contacted the H.R. department to ascertain if they could provide evidence that a POVAFirst check had been carried out, but this could not be located by staff. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 25 There was no evidence that an appropriately qualified and experienced member of staff had been appointed to supervise the new worker pending the receipt of a CRB (who is so far as is possible, on duty at the same time). It was also found that on at least one occasion (10 June 2006), the member of staff had worked unsupervised and alone on one of the flats. There was no written risk assessment on the file to demonstrate what action the former manager had taken to minimise the risk to service users whilst awaiting the return of a CRB check, and there was no previous discussion with the Commission for Social Care Inspection about the appointment of this member of staff, as is good practice. No formal supervision of the member of staff had taken place since appointment. Another member of staff had no CRB or POVAFirst check available for inspection (according to records and interviews they were started pending the return of a CRB check which has since been received). There was no written risk assessment on the file and no copy of a recent photograph. An Immediate Requirement was issued to address these issues. There was no central staff training and development programme. Individual staff training certificates were examined to determine the level of training undertaken. Some training certificates were not available although staff confirmed during interview that they had undertaken this training, for example accredited safe handling of medication. Whilst improvements have began with regard to providing staff with specialist induction training by an accredited learning disability awards framework (LDAF) provider, overall progress is very slow. In particular, new staff are not completing this training within the first six weeks of appointment as the manager is having to also include existing staff and there are insufficient places available. The manager stated that two staff have now completed induction training. The manager acknowledges that formal staff supervision requires improvement. This was evidenced on examination of one person’s supervision records which demonstrated this had not taken place since June 2005. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 26 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): 37, 39 and 42 The overall outcome for this group of standards is judged to be adequate. The new manager has already started to introduce new systems to benefit residents and staff. Quality assurance systems require development so that residents and other users can be confident their views underpin the development of the service. Overall there is good health and safety practice although some elements need improvement in order to offer residents more safeguards particularly with regard to staff training. EVIDENCE: Since 31 May 2006 a new acting manager has been in post who had already been working at the home in a senior support worker role. Mrs. Morgan has the required qualifications for the post of manager and during this visit demonstrated a dedicated and caring approach to residents and staff. During interviews staff stated that they felt communication was much improved and that they felt Mrs. Morgan was helpful and supportive. There are regular staff Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 27 meetings and one was held during the inspection. A new system for care planning has already been conceived which was discussed at the meeting. Mrs. Morgan has already introduced a clearer system for staff with regard to accident and incident reporting and is keeping a central file for monitoring purposes as is good practice. It was also reassuring to see that Mrs. Morgan had devised a flow chart displayed in the main office for staff to follow when reporting and identifying an incident of vulnerable adult abuse. A meeting was requested by the providers and subsequently held with the CSCI on 19 May 2006. Future plans for the home were discussed and the providers were going to inform the Commission in writing as to the future management and proposals for the home which have so far not been received. An application for registration of the manager must therefore be presented to the Commission without delay. There has been no further progress with regard to quality assurance systems and no annual development plan in place. The former manager had devised questionnaires for residents and stakeholders but these had been awaiting corporate approval. The new manager was unaware as to whether any further progress had been made in this aspect. A sample of maintenance and service records were examined and found to be largely up to date with only a couple of exceptions. For example, fire alarm testing needs to be carried out more consistently on a weekly basis. The water log book had been mislaid and no tests had recently taken place. The inspector gave a sample proforma as an interim measure. The laundry door on flat two was found unlocked and the cupboard also containing hazardous substances was also unlocked. All other aspects of health and safety were found to be good. However staff mandatory training is poor. For example, according to training certificates only eleven staff have up to date training in first aid awareness, only three staff have up to date training in health and safety, and only four staff have up to date training in food hygiene and infection control. Fire safety training had recently been undertaken by the majority of staff. It is not acceptable for the home to have such low levels of trained staff; it was however reassuring that future training has been arranged to take place over the next five months including first aid, infection control and vulnerable adult abuse. However, if this training does not take place then the Commission will have to consider further action. Food hygiene practice was examined in a couple of flats. Fridge and freezer temperatures are checked daily but these were found to be unacceptably high. On further discussion the manager could demonstrate that action had already been taken, however, staff must record what action they take on a daily basis when a temperature is found to be too high. There is regular testing of cooked food temperatures (it was pleasing to see that this had been discussed Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 28 at a recent staff meeting). There are a couple of minor improvements required: dried foods must be stored in pest proof containers once opened and frozen foods must be labelled with the date of freezing. Any other items discussed during this inspection are contained within the Requirements section of this report. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 29 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 1 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 1 X 2 X 1 X X 2 X Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 30 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 YA6 Regulation 15(1) Requirement To develop a rigorous and robust care planning system and ensure that it incorporates all aspects of care/support required for individual service users. This must also cover healthcare and social and recreational activities to ensure a holistic approach to care planning (Previous timescale of 1/1/04 is not met). The service user must be involved in this process (person centred planning), and all care plans must be signed by the service user. (Previous timescale of 1/1/04 is not met). Reviews of care plans must be undertaken at least every six months. (Previous timescale of 1/1/04 is not met). Care plans must also be produced in a format suitable for service users. (Previous timescale of 1/1/04 is not met). Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 31 Timescale for action 01/02/07 2. YA8 12(3) To offer more opportunities for 01/02/07 service users to participate in the day to day running of the Home through joining staff meetings, representation in management structures, recruitment and selection of staff. (Previous timescale of 1/1/04 is not met). To review and expand risk assessments to ensure that there are written risk assessments established for all aspects of service users lives which pose a risk, for example: wheelchair use, epilepsy, incontinence etc. To review and expand weekly activity planners to ensure that they are fully completed for all service users and are extended to cover weekend activities (planned and spontaneous). To undertaken a documented review staffing levels at weekends to ensure that they are appropriate to meet the needs of service users. (Previous timescale of 1/6/05 is not met). To improve record keeping with regard to activities undertaken, monitoring and evaluation. 01/01/07 3. YA9 13(4)(c) 4. YA14 16(2)(n) 01/01/07 5. YA16 16(2)(b) To provide a telephone facility for service users which affords more privacy. (Previous timescale of 1/3/04 is not met). To ensure that any restrictions on choices are negotiated with 01/01/07 Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 32 all individual service users and advocates. Outcomes to be recorded in service user plans and reviewed regularly: for example the decision to not to provide bedroom door keys, and the opening of service users mail. 6. YA17 16(2)(i) To record individual service users chosen options for breakfast, lunch and dinner. 01/01/07 7. YA18 17(1)(a) 8. YA19 12(1)(a) To re-introduce a recognised nutritional screening tool for assessment and reviewing of nutritional needs. To ensure that preferences and 01/02/07 restrictions on residents’ choices be negotiated, included in service user plans and reviewed regularly: decision to not provide certain items of furniture as required by Standard 26, personal care given by opposite gender staff, preferred bed times, bath times etc. (Previous timescale of 1/1/04 is not met). To make the following 01/12/06 improvements to health care: To ensure that the ‘priority screening for health care’ booklets are kept up to date (and reviewed), and all sections are fully completed. (Previous timescale of 1/10/04 is not met). To ensure that care plans are expanded for diabetic service users. These must include guidelines for management of diabetes, screening, monitoring and potential complications. (Previous timescale of 1/10/04 is not met). Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 33 To ensure that all service users receive more regular and consistent weight checks which are fully recorded. (Previous timescale of 1/12/05 is not met). To introduce a procedure for the monitoring of service users health to supplement annual attendance at well person clinics with regard to potential complications such as breast cancer and testicular cancer etc. Specific care plans must be developed for these areas of health care screening with guidance to service users (if appropriate) with regard to selfexamination. 9. YA20 13(2) To make the following improvements to the control and administration of medication: To review and expand the medication policy to include all subjects: staff training, drug hazard alert notices, key holding etc. (Previous timescale of 1/3/04 is not met). To ensure that there is more consistent recording of the administration of creams and ointments on MAR sheets held in service users’ bedrooms. (or in central folders in flats). (Previous timescale of 1/6/06 is not met). To improve administration of medication and recording on the medication administration record (MAR) sheets. For example all gaps must be explored with written explanations obtained. Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 34 01/12/06 (Previous timescale of 1/12/05 is not met). To ensure that when any changes of medication are made on the MAR sheets by staff, such as the addition of new medication, two staff initials are obtained to confirm accurate instructions have been recorded. (Previous timescale of 1/12/05 is not met). To ensure that night staff who administer medication are provided with accredited training in the safe handling of medication. (Previous timescale of 1/05/06 is not met). To ensure that urine testing is carried out at the frequency identified in the MAR sheet folder. To ensure that there is consistent recording and monitoring including service users’ refusals. A staff competency monitoring procedure to ensure the correct administration of medication must be developed and completed on a regular basis with records maintained. To establish written procedures for the secondary dispensing of medication on behalf of one service user when going on social leave, and for the sending of the monthly monitored dosage system packs with other service users going on social leave. These must include systems for monitoring and checking medicines. Advice must also be Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 35 sought from the local pharmacist with documented records maintained. To ensure that detailed guidelines are established for all ‘as and when required’ (PRN) medications for pain relief – for example: when precisely the medication can be administered, what the initial dose to be administered is, what the maximum daily dosage is, how long the treatment should be continued for before further advice. To ensure that where staff are deviating from the computerized instructions on the MAR sheet with regard to the administration of Paracetamol on behalf of one service user, who is supposed to be receiving two tablets, four times daily, but is being administered one or two tablets as a variable dosage – that advice is sought from the prescriber and the correct instructions entered onto the MAR sheet. 10. YA22 22(8) To amend complaints procedure to include details of the CSCI local area office. (Previous timescale of 1/7/03 is not met). To provide all staff with training in vulnerable adult abuse awareness. (Previous timescale of 1/1/04 is not met). Any behaviour management plan must be agreed within a minuted multi disciplinary forum and included in a care plan. For Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 36 01/02/07 11. YA23 13(6) 01/12/06 example: to discuss current management behavioural techniques for one service user which includes the physical intervention of escorting the resident to their bedroom, with specialists (such as psychologists) and to obtain their approval or advice. To ensure that outcomes are included in care plans with comprehensive guidelines introduced for staff. 12. YA24 23(2)(b) To replace worn and stained settees and dining room furniture in flat no. 3. (Previous timescale of 1/12/05 is not met). To address noisy floorboards in flat nos. 3 and 4. (Previous timescale of 1/6/06 is not met). To make safe the area around the back of the premises (or any other part of the premises which poses a risk to health and safety), where tiles have fallen onto pathways – within twenty four hours of the inspection by 28 July 2006. IMMEDIATE REQUIREMENT To carry out an inspection of the tiled walls and to undertake any identified repairs within one week of the inspection by 2 August 2006. IMMEDIATE REQUIREMENT To clean or replace stained carpets in communal areas in all flats and main lounge. To replace worn and stained settees and dining room Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 37 01/01/07 furniture in flat four. To undertake a written risk assessment with regard to security arrangements in view of the new proprieties which have been erected in the grounds of the home. To undertake a written consultation with service users regarding privacy arrangements in respect of those that are affected by the new buildings. 13. YA30 13(3) To make the following improvements to infection control: To ensure that mop heads are laundered daily at thermal disinfection temperatures and are dried appropriately (inverted). (Previous timescale of 1/6/05 is not met). To ensure that all bathrooms are kept free of communal items such as plastic jugs used for rinsing hair. (Previous timescale of 1/5/06 is not met). To improve infection control practice and address all items identified in this report as requiring attention. 14. YA32 18(1)(c) To ensure that all staff are working to obtain an NVQ II or III by an agreed date; or the Manager must provide evidence to demonstrate that through past work experience staff meet this standard. (Previous timescale of 1/5/04 is not met). DS0000024984.V305269.R01.S.doc 01/12/06 01/01/07 Glebelands Version 5.2 Page 38 To ensure that 50 of care staff achieve an NVQ II by 2005. (Previous timescale of 1/1/06 is not met). To provide all staff with training in understanding and managing challenging behaviour. (Previous timescale of 1/6/06 is not met). 15. YA33 18(1)(a) The Manager must undertake an 01/12/06 up to date review of staffing ratios and service users dependency levels. To forward proposals to the Commission for Social Care Inspection. Sufficient staff must be allocated on a daily basis to provide all service users with a range of stimulating activities and to meet personal development needs. To ensure that the CSCI is notified of any failure to provide sufficient staff on duty per shift. To ensure that criminal record bureau disclosure (CRB) and Protection of Vulnerable Adult (POVA) checks for new staff are held on the premises and available for inspection. (Previous timescale of 1/6/06 is not met). To cease the employment of any new staff without obtaining all of the pre-employment checks required by the Care Homes Regulations 2001, Regulation 19 (copies to be held on the premises and available for inspection). IMMEDIATE REQUIREMENT BY 27 JULY 2006. 16. YA34 13(6) 31/07/06 Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 39 To ensure that if staff are employed on a POVAFirst check, pending the return of a satisfactory CRB check, that all of the requirements of the Care Homes Regulations 2001, Regulations, 19(10) and (11) are complied with. A written risk assessment must also be carried out with a copy forwarded to the Commission for Social Care Inspection. IMMEDIATE REQUIREMENT BY 27 JULY 2006. To obtain all of the required information and documentation missing from any new staff files within five days of the inspection by 31 July 2006. IMMEDIATE REQUIREMENT. 01/02/07 To amend induction/foundation training to ensure it meets the Sector Skills Council specification. To ensure that this training is carried out by a Learning Disability Awards Framework accredited provider. To ensure that induction is completed within the first six weeks of employment and foundation, within the first six months. (Previous timescale of 1/7/03 is not met). To provide a central staff training and development plan to be held on the premises and available for Inspection. (Previous timescale of 1/1/04 is not met). To provide all staff with training in equal opportunities and disability equality. (Previous timescale of 1/1/04 is not met). 17. YA35 18(1)(a) Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 40 18. YA36 18(2) To ensure that structured supervision of staff is carried out bi-monthly. (Previous timescale of 1/1/04 is not met). To provide all staff with an annual appraisal. (Previous timescale of 1/1/04 is not met). 01/02/07 19. YA37 9 20. YA39 24 The provider must ensure that an application to register a manager in respect of the Glebelands is submitted to CSCI by the date given. To develop an effective quality assurance system to include feedback from service users, stakeholders in the community etc. (Previous timescale of 1/1/04 is not met). To establish an annual development plan for the home based upon a systematic cycle of planning and review. 30/11/06 01/02/07 21. YA42 18(1)(a) To provide training for all staff commensurate with their duties in the following areas: 1) Moving and handling. (Previous timescale of 1/1/04 is not met). 2) infection control. (Previous timescale of 1/1/04 is not met). 3) training in emergency breakdown procedures (or to ensure staff read and sign a policy which describes what action to take in the event of a 01/02/07 Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 41 breakdown). (Previous timescale of 1/1/04 is not met). 4) First aid awareness. 5) Health and Safety. To ensure that all training certificates are held on the premises to evidence that training has been undertaken. 22. YA42 12(1)(a) To ensure compliance with Control of Substances Hazardous to Health Regulations 1988 - to carry out and update individual risk assessment on products used. .(Previous timescale of 1/1/04 is partly met). To ensure that staff take appropriate action which is fully recorded, when fridge or freezer temperatures are found to be either too high or low upon daily testing. (Previous timescale of 1/6/06 is partly met). The Acting Manager is required to improve food hygiene practice and address items identified in this report. To reinstate regular (at least monthly) testing of water temperatures from all outlets with appropriate records maintained. To improve the consistency of weekly fire alarm tests. To ensure that substances hazardous to health (COSHH) are held secure at all times (for example, the laundry area of flat two), or to demonstrate through Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 42 01/02/07 a risk assessment why this is not necessary. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA8 YA20 Good Practice Recommendations To improve frequency and recording of service users’ meetings. To consider introducing a procedure for auditing and balancing medications which are not received on a monthly cycle in the monitored dosage system such as PRN pain relief medicines. To consider introducing the complaints procedure in varying formats for example audio. To provide awareness training for staff in cerebral palsy and diabetes awareness. To provide awareness training for staff in tissue viability, Makaton, epilepsy and person centred planning styles. 5. 6. YA42 YA42 To establish a documented Legionella control scheme as recommended following a Legionella risk assessment. To establish written guidelines for staff when testing fridge and freezer temperatures using the new maximum/minimum thermometer. These must include actions to be taken if temperatures are too high or low (which must be fully recorded). To ensure that wheelchairs receive regular health and safety checks, which are fully recorded. 3. 4. YA22 YA32 Glebelands DS0000024984.V305269.R01.S.doc Version 5.2 Page 43 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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