Inspection on 13/06/05 for 29 Greenhill Road (westholme)

This inspection was carried out on 13th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 35 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

29 Greenhill Road (westholme) 27/10/08

29 Greenhill Road (westholme) 30/10/07

29 Greenhill Road (westholme) 06/12/06

29 Greenhill Road (westholme) 13/06/06

29 Greenhill Road (westholme) 27/10/05

29 Greenhill Road (westholme) 24/02/05

29 Greenhill Road (westholme) 29/12/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Westholme 29 Greenhill Road (WestHolme) Moseley Birmingham B14 9SS Lead Inspector Alison Ridge Unannounced 13th June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service West Holme Address 29 Greenhill Road, Moseley, Birmingham B14 9SS. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 449 6383 0121 449 6573 TRACS Vacant Care Home 14 Category(ies) of Learning Disabilities ,Physical Disabilities (14) registration, with number of places Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 .Residents must be aged under 65 years .2. 14 people requiring care for reasons of learning disability or acquired brain injury (14 LD,PD) Date of last inspection 28th February 2005 Brief Description of the Service: 29 Greenhill Road, comprises of two units, TRACS Westholme, and TRACS Hilltop. Tracs Westholme is registered to accomodate ten people under the age of 65, who have a Learning Disability or Acquired Brain injury. Three of the rooms within the accomodation on the ground floor have been adapted to support people with impaired mobility. The remaining bedrooms are on the first floor, and full mobility is required to access these rooms. This part of the home has a communal lounge, dining room, smoke room, kitchen, and bathrooms and toilets on both floors. TRACS Hilltop occupies the second floor of the home. Hilltop provides care and support for four service users working towards more independent living, offering people the opportunity to develop skills such as budgetting, cooking, home making, and taking greater responsibility for planning their lifestyle.This area of the home has a seperate staff team, and its own facilities such as a lounge, kitchen and bathroom. The home has a large, mature garden at the rear. The home has transport, and is located close to local bus routes. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook an unannounced inspection over the morning of one day. The inspection focussed on progress made towards meeting previously made requirements, and on talking with people that live in the home regarding their experiences of living there. Both inspectors spent time talking with people who live in the home. Inspectors also undertook a tour of the home, observed interactions between service users and staff, examined staff records, care records and health and safety records. The inspectors were also pleased to meet with the homes acting manager. Four of the previously made requirements were not assessed during the inspection. This is related to CSCI constraints, and should not be viewed negatively against the provider. Information received from the provider after the last inspection identifies work to address these matters has been undertaken. What the service does well: The home has been subject to a lot of building work recently. The rooms that have been changed and redecorated were seen to be spacious, and pleasant, and people that live in the rooms reported being pleased with them. The home is good at helping people stay in touch with their family and friends. Even if these people don’t live locally. During the inspection people who live in the home talked about writing letters, making visits and phone-calls to their family and friends. The staff on duty during the inspection helped the people who live in the home to undertake activities, including going out, or just sitting and talking to them. People who live in the home said staff are helpful, and supportive. The people that live in the home and staff chatted easily during the inspection. Staff introduced themselves to people that live in the home at the start of the shift. The people that live in the home all appeared to be well dressed, and to have been supported with their personal care. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 6 In conversation and in care records it was apparent that people who live in the home are supported to visit the hairdressers, buy clothes and toiletries, and undertake personal care each day. The care plans say how each person likes to be helped with this. People who live in the home said the food provided was good. Although some problems were identified, plenty of good food was available. The menu was varied. The home is good at asking people about the things they would like to do, and how they would like to be cared for and supported. What has improved since the last inspection? What they could do better: The inspectors could not see that all the required checks had been made on people recently employed, before they started work in the home. Risk assessments must get better, and the home ensure that staff follow the guidance given in the document. The homes management continues to be a cause of concern, and this is an area that must improve. Storage of foods, including foods that are chilled and frozen must get better. Recording what each person has done each day, including what food people have eaten must improve. The home has 24 requirements that have been previously made, that remain unmet. These must be addressed. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 7 Cultural needs of people that live in the home need to be better met. 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. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 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 standard(s) 1 Service users are given information in an accessible format, which enables them to make a choice about where to live. EVIDENCE: Copies of the Statement of Purpose and Service Users Guide for both Westholme and Hilltop have been assessed. (Edition March 2005) The documents have recently been reviewed, and the inspector assessed them against National Minimum Standard one and Regulations 4 and 5. The inspectors general comments were that the documents were well presented, easy to handle and to read. The Service Users Guide is available on Audio Cassette. Both documents give people interested in moving to the home, or who live in the home a good impression of the service and facilities available. Specific comments are, Westholme and Hilltop Statement of Purpose, 1. The age range of service users that can be accommodated should be more specific, and not cover the entire 18-65 age spectrum. 2. The home details well the needs it is able to meet, but is not specific about the level or type of challenging behaviour that can be managed. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 10 3. The admission information does not inform the reader that overnight stays and trial visits are possible. 4. Opportunities for social and leisure activities are not stated. 5. The arrangements for review of the Service users plan are detailed to be the responsibility of the key worker. This must be the responsibility of the manager. Westholmes Service User Guide, 1. The inspection report attached is not current (This is very outdated 11 and 12 March 2003) 2. The additional information must be available 3. The age range of service users should be more specific and not 18-65, 4. The home details well the needs it is able to meet, but is not specific about the level or type of challenging behaviour that can be managed. 5. When available room sizes must be given. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,9,10 Records of care contain some very detailed and personal information, however they do not fully underpin service users needs. Therefore service users needs are not well planned, or risks well managed. EVIDENCE: The individual plan of two of the service users were assessed at this inspection. The daily notes written by staff, generally contained greater detail regarding incidents and occurrences, giving a greater impression of what had occurred and the support given. Notes had not been made for all the days sampled, and pages did not all follow on from each other, and were in places difficult to track. The plans sampled had been recently reviewed. The plans showed consultation with the service user, and it contained goals, and aspirations of the service user, as well as clinical needs. The need to ensure that goals service users express are planned and progressed towards continues to require attention. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 12 In one plan tracked goals including using a communication book and eating Caribbean meals fortnightly were listed. Inspectors commented that this is a low ratio of culturally appropriate meals for someone of this culture. It has been required this be further explored with the service user to ensure this is to his satisfaction. In the daily notes tracked it was not apparent these meals had been offered or eaten. One inspector spent some time on Hilltop. The plans sampled had been reviewed regularly, including a formal six-month review. The staff the inspector spoke with was knowledgeable regarding the service users needs. These will be further assessed at future inspections. Risk assessments for four service users were sampled. Clinical risks people face that include pressure injury, choking and falls were assessed. The practice observed at breakfast time with one service user, was significantly different to the risk assessment regards this. This could lead to the service user being placed at risk of choking. One service user who continually utilises a wheelchair was tracked. No assessment regards the risk of pressure injury was available. It was positive that the home has identified risks to service users welfare from other service users and had assessed these. Work to formulate strategies to support service users and ensure the documents work in practice is required. Inspectors consider it positive practice that risk assessments are stored with care plans, and that the review process is auditable. Risk assessments for service users living on Hilltop that access the community independently must be developed. It has previously been required that pages of service users daily notes be numbered and held securely on file. This remains an area requiring attention to ensure notes are retained confidentially, and securely. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 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 standard(s) 17 Food offered is varied, and generally to service users satisfaction. Records of food eaten, menus and food storage must improve to evidence service users are receiving a nutritionally balanced diet. EVIDENCE: The menus, records of food eaten and food available were tracked. Service users reported favourably regarding the breakfast meal, and were seen to be offered choices. Records of food eaten were incomplete, and the records made were not in enough detail to enable the nutritional intake of the service user to be assessed. Staff must report in more detail than “Brunch”, “Pork Dinner” for example. The menus sampled were not dated, and cross referencing these with the records of food eaten was not successful. This area requires further review to ensure service users are being offered a balanced diet, including food of their choice where possible, and that a record of this is maintained. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 14 Food storage has previously been identified as requiring review. This was again found to be of concern. Three loaves of bread past the best before date, that were stale, were observed. Dry goods had not been stored appropriately, and chilled and frozen goods, that were not well labelled or wrapped were observed. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Service users are supported with personal care to a high standard. Medication was well managed ensuring service users receive the correct medication at the correct time. Healthcare needs were not all well planned, which could result in healthcare needs being unmet. EVIDENCE: Service users the inspectors met with all appeared well presented, and it was apparent through conversations, and from care records that service users are supported to undertake personal care regularly. The morning and evening routines in two of the service users files sampled were very detailed, and showed consultation with the service users. Inspectors commented that these were very individualised, and would promote continuity of care. The matrix regarding personal care offered and delivered was not consistently completed in the files sampled. It is recommended the use of this be reviewed. The way in which the home meets service users healthcare needs was assessed. Plans were good regarding access to the multi-disciplinary team, general care and primary health care. Inspectors tracked the way in which specific health needs had been planned. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 16 One service users assessment identified he had mental health needs. This was not reflected in the care plan, and inspectors could not establish indicators of well being, or indicators of change. One service user tracked was identified to have a low body weight at admission. The care plan stated, “Weigh monthly and report any concerns”. The plan did not detail the current body weight, the plan to increase this, what concerns might be, or the goal body weight. Weight had not been recorded since admission. It was generally apparent that service users had been supported to attend appointments with the GP, Dentist, Chiropodist and Optician as required. One example of poor practice where broken dentures had been identified as requiring replacement in April 2005, remained outstanding. (A temporary mend had been arranged). The provider notified the CSCI in their action plan that this was due to the dentist cancelling appointments. In one file, records prior to May 2005 had been archived, and it was not possible to establish when appointments had last been attended. The need to ensure follow up care is undertaken as required was identified in one of the files sampled. An example of a specimen being forwarded to the GP for analysis in May 2005 was identified at the inspection. It was not possible to establish from the records available the result of this, or if any required treatment had been obtained or given. Medication on Westholme was assessed. Three of the previously made requirements had been met in full, two were not assessed. Medicine management appeared to be good. The home must ensure Protocols for all As Required Medicines are available. These had not yet been developed for the most recent service user admitted to the home. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Service users present a risk to each other, and strategies to protect service users did not fully address this, which could result in service users being placed at risk of harm. EVIDENCE: The action taken by the home to ensure service users are physically and psychologically protected from harm was assessed. Records included assessments for the risks some service users pose to each other. This was not available for all service users. In the morning, prior to day staff arriving on shift, supervision and support for service users who had already risen from bed was significantly lower than is available during the day, and significant periods when service users were unsupervised were observed. Risk assessments must reflect this, and a review of the staff allocation undertaken. During discussion, and from reading service users records the needs of one service user were identified as causing concern to other service users. Mention of this had been made in the service users plans, and risk assessments. It was not apparent this had been managed to the satisfaction of the people affected. Further work was identified to be required to ensure the safety and welfare of the service users accommodated. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,27,28,30 The environment at 29 Greenhill Road is improving. When work is complete it will ensure the comfort and safety of service users. At this inspection cleanliness, bathrooms and odour control all required attention. EVIDENCE: The premises at both Westholme and Hilltop have been subject to significant development in the past few months. The work remains ongoing, and some parts of the home remain under development. It is anticipated when complete this will improve the improve the accommodation for service users significantly. A partial tour of the premises was undertaken. This identified that further work was required on the ground floor WC. This was presented in a poor condition, was odouress and had broken tiles. One inspector spent time with a service user, who kindly showed her bedroom. The usable space and presentation of the room was unacceptable as it was. It was reported this lady would be moving into one of the new rooms. It was not cleat which room this was. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 19 Neither the service user or staff on duty could clarify this. It has been required that arrangements for bathrooms and toilets on the ground floor be clarified. At present it is not clear if one of the bathrooms is to be a shower room or toilet. The garden had many uneven slabs that pose a trip hazard. The large amount of waste from smokers, discarded in the garden did not identify that adequate safe disposal facilities were in place. The front garden of the home was not as well presented as usual. Planters required renewing, and some rubbish was evident on the path and garden. Food storage has previously been identified as requiring attention. At this inspection food past the best before date was identified within the kitchen. Some food items in the fridge and freezer were not well wrapped or labelled. The new laundry area was identified to be an improvement on the previous building. At the time of inspection the door was propped open. This must be kept closed. Again work in here to complete the room was ongoing. One of the bedrooms assessed was odouress. This has been identified on previous inspections, and continues to require more effective management. Building work in one bedroom inspected had recently been completed. Work to finish the room (such as provision of a lampshade, and the commissioning of the ensuite) was required. The development of the kitchen on Hilltop was assessed and considered to be very positive. Good infection control practice was not observed in the ground floor bathroom. Four bars of soap and four sponges were identified. It was not clear to whom these belonged. The bin in this bathroom did not have a lid. The shower fitting over the bath was observed to be broken. Light chords in bathrooms and toilets remained dirty. It is an unmet requirement that these be cleaned. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34 Recruitment records for one staff did not identify recruitment practices that would ensure service users safety. The frequency of supervision for the one staff sampled was poor, and did not ensure she had been adequately supported to meet service users needs. Staff demonstrated a good knowledge of service users needs. EVIDENCE: Recruitment records for one recent staff starter was assessed. It was of concern that in that file neither a CRB or POVA First disclosure was available. An immediate requirement regarding this matter was made at the time of inspection. No photograph was available in this file. The recruitment file of another more established staff member was assessed, all required documents were available. The most recent records of supervision were dated November 2004 and August 2004. These must be undertaken with greater frequency. Inspectors found the minimum number of staff on duty to have been maintained. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 21 It was evident in the early morning, when inspectors arrived at the home that there were not adequate staff to assist service users with their morning routine, prior to day staff arriving. Some service users were observed to be up and requiring assistance with personal care, a drink or breakfast. At the time the two night staff were completing reports, and later providing the day staff with a handover. It has been required that staff provision at this time of day be reviewed and action as identified undertaken. Staff on duty that assisted with the inspection on both Westholme and Hilltop had a thorough working knowledge of the service users inspectors asked about. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,41,42 The management and operation of the home does not ensure that outcomes for service users are safe, well planned; or consistently met. EVIDENCE: The post of Registered Manager is currently vacant. The CSCI has expressed concern regarding the management of the home, as at present arrangements do not ensure service users needs are consistently well met. The CSCI has raised these concerns with the provider. Records of care must be completed consistently, and attention needs to be paid to ensuring pages are numbers, and pages follow on from each other in an auditable way. The inspection identified that the record of food eaten had not been consistently maintained. This must be addressed. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 23 The fire risk assessment states that there are people accommodated in the building that would be unable to react quickly in the event of a fire, or be able to evacuate (Point 3.3) No work to explore this further or to ensure the safety of these people was evident in the fire risk assessment or supporting documents. Records of fire alarm and emergency light tests do not evidence that these are undertaken and recorded with the required frequency. It is positive that accident records are analysed by the provider. It was not evident how the information is used to reduce or eliminate the risk of an accident re-occurring. The water in the ground floor bathroom was found to require attention to ensure delivery was at 43 degrees Celsius. Locks on service users bedroom doors, remain of concern. The current arrangements means that a door locks closed and a key is required to regain access. Not all the service users accommodated are able or wish to hold the key, which results in them requiring staff support to regain access. The style of locks must be reviewed. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 x 1 3 x 1 Standard No 11 12 13 14 15 16 17 x x x x x x 1 Standard No 31 32 33 34 35 36 Score x 3 2 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westholme Score 2 1 2 x Standard No 37 38 39 40 41 42 43 Score 1 x x x 2 2 x E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 25 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 YA1 Regulation 4(1)(2)(1 7(2) Schedule 1 5(1)(2)17 (2) Schedule 4(2) 15(1) Requirement The statement of purpose must be developed as identified at standard 1 The service users guide must be developed as at standard 1 Service user plans must show how a service users needs in respect of their health and welfare are to be met Goals must clearly state how they are to be met, who is responsible, and how it will be known if they been achieved. Risk assessments for clinical risks service users face including falls, choking and pressure injury must be completed. Timescale for action 1/11/05 2. YA1 1/11/05 3. YA6 4. YA6 5. YA9 12(1)(a) and 15(2)(bd) 13(4)(a-c) Unmet from the previous inspection. 1/9/05 1/9/05 6. YA9 7. YA9 13(4)(a-c) Risks that service users pose to each other due to their complex and sometimes challenging needs must be assessed and control measures explored and implemented. 12(4)(a) Risk assessments for service users accessing the community to be developed E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Unmet from the previous inspection. 1/9/05 Unmet from the previous inspection. 1/9/05 14/9/05 Westholme Version 1.30 Page 26 8. YA10 12(4)(a) The pages of care notes must be secured to ensure they are safe and confidentiality is protected. The provider must ensure all relevant healthcare monitoring is undertaken. Indicators of service users mental well being must be included in the service users plan, or clearly signpost the reader to this information where this care is required. Weight monitoring must be undertaken consistently, and records developed to show where, the time and date the weight was recorded. Not assessed. The provision of medication for service users regularly out of the home, at the time medication is administered must be explored. Protocols for all,” As required medications” (PRN) must be provided. 9. YA19 12(1)(a) and 13(1)(b) 12(1)(a) and 13(1)(b) and 15 12(1)(ab) 10. YA19 Unmet from the previous inspection. 14/9/05 Unmet from the previous inspection. 14/9/05 Unmet from the previous inspection. 14/9/05 Unmet from the previous inspection. 14/9/05 11. YA19 12. YA20 13(2) 13. YA24 13(4)(a)(c Slabs in the garden must be ) levelled and secured. Unmet from the previous inspection. Unmet from the previous inspection. 1/10/05 8/8/05 Unmet from the previous inspection. 1/10/05 14. YA24 23(2)(b) Recepticles for safe disposal of smoking materials must be provided. Kitchen cupboard doors must be hung securely. The dent in the first floor radiator must be repaired or replaced. Standard not assessed at this inspection. 15. YA26 23(2)(b) Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 27 16. YA26 23(2)(b) There are health and safety concerns with one service users bedroom the home must continue to devise interventions to minimise this Rooms must be presented to a satisfactory and safe standard prior to service users moving in to them. The new bedroom arrangements for one service user must be agreed and the service user informed. The ground floor toilet must be upgraded and presented to an acceptable standard. The overbath shower fitting in the ground floor bathroom must be repaired. The ground floor bathrooms and toilet facilities must be clarified and confirmed to the CSCI. Unmet from the previous inspection. 8/8/05 17. YA27 23(2)(b) and 23(2)(j) 8/8/05 18. YA30 12 (4)(a) and 13(3) Good infection control practice regarding toilettries must be utilised. Lidded bins must be provided in bathrooms Light chords in bathrooms require cleansing or replacement. With providers response to report 8/8/05 19. YA30 13(3) Unmet from the previous inspection. 1/9/05 Unmet from the previous inspection. 8/8/05 Unmet from the Page 28 20. YA30 16(2)(k) and 23(2)(d) Odour control must be maintained in all areas of the home. Standards of cleanliness must be maintained at a satisfactory level in all areas of the home Food must be wrapped and labelled with the date of 21. YA30 13(3) Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 opening. All open foods must be appropriately stored. 22. 23. YA33 YA34 18(1)(a) 19 A review of the morning staffing must be undertaken, and action as identified implemented. Recruitment records must evidence that robust checks have been undertaken prior to staff commencing work in the home. Not assessed at this inspection. Mandatory and service user specific training must be delivered to staff as required. Evidence this has been planned and delivered must be maintained in the home The management arrangements of the home must be reviewed to ensure these are effective and adequate Not assessed at this inspection. previous inspection. 1/8/05 19/9/05 For all new staff 4/8/05 and ongoing. 24. YA35 18(c ) 25. YA37 8 and 9 1/9/05 26. YA41 13(6) 27. 28. YA41 YA42 29. YA42 The service users financial profiles must be accurate. The personal allowance paid to one service user must be reviewed to ensure this is the full amount. (Refund of any underpaid funds must be made) Service users must have individual bank accounts. 17 Records (Including records of 1/9/05 food)must be in order, dated audittable and fully completed. 13(4)(a-c) COSHH hazard sheets must be Unmet reviewed and updated. from the previous inspection. 1/10/05 13(4)(a-c) Not assessed at this inspection. Risk assessments must be developed to underpin the risks and detail the control measures for staff when at work. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 29 30. YA42 31. YA42 32. YA42 33. YA42 34. 35. YA42 YA36 Locks on service users doors must be reviewed, to ensure service users welfare and freedom of movement is maintained. 13(4)(a-c) The information obtained from the accident report audit must be utilised to reduce the likelihood or repeat of similar incidents 23(4)(a) The fire risk assessment must be developed to show control measures for concerns/issues that have been raised. 23(4)(c Fire safety checks and )(iv) emergency lighting tests must be undertaken as required and a record made. 13(4)(c ) Hot water delivery must be controlled at 43 degrees celcius. 18(2) All staff must receive supervisions at least bi-monthly, and a record of these maintained. 12(1)(a) and 13(6) Unmet from the previous inspection. 1/11/05 Unmet from the previous inspection. 1/10/05 1/10/05 14/8/05 14/8/05 1/9/05 36. 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 YA18 Good Practice Recommendations It is recommended that the use of the personal care matrix be reviewed. Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection Birmingham & Solihull Local 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 Westholme E54_S16713_GreenhillWesth_V228781_230505 stage 4.doc Version 1.30 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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