Inspection on 23/07/07 for John Dando Residential Centre

This inspection was carried out on 23rd July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

John Dando Residential Centre 29/08/06

John Dando Residential Centre 27/02/06

John Dando Residential Centre 04/07/05

John Dando Residential Centre 09/11/04

John Dando Residential Centre 24/05/04

Similar services:

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Maple Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE John Dando Residential Centre Hamstead Road Great Barr Birmingham B43 5EL Lead Inspector Mrs Cathy Moore Key Unannounced Inspection 23rd July 2007 07:05 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address John Dando Residential Centre DS0000034187.V341668.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service John Dando Residential Centre Address Hamstead Road Great Barr Birmingham B43 5EL 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) 0121 357 7574 0121 357 9425 bhellend@hotmail.com Sandwell Metropolitan Borough Council Tracey Elizabeth Lewis Care Home 39 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (19) of places John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 9 & 10 January 2003 are met within the timescales contained within the action plan agreed between Sandwell Metropolitan Borough Council and the National Care Standards Commission. One service user identified in the variation report dated 9 June 2004 may be accommodated in the category of PD(E). This will remain until such time that the service users placement is terminated. 29th August 2006 2. Date of last inspection Brief Description of the Service: John Dando is located in Great Barr, close to the Birmingham/Sandwell border. It is situated in a residential area, a school, community centre, library, pub and small shops are all close by. Bus routes are available locally enabling access to other local areas and facilities. The home is owned and managed by Sandwell Council. The home comprises of two floors, providing thirty-nine single bedrooms. Internally the home is divided into four sections or units. Three sections or units are on the ground floor and one big section/ unit on the first floor. All of these different sections/ units have their own toilets, an assisted bathroom, lounge, dining and individual resident accommodation. There is one main laundry. The main kitchen prepares, cooks and serves all food for the individual units within the home. The home is registered with the Commission for Social Care Inspection ( CSCI) to provide personal care to a maximum of 39 older people. Twenty of these places are allocated to service users who have a diagnosis of dementia, Nineteen to older people who do not have other needs. The fees for this home range from £98.60 (respite) to £485 per week. Additional charges apply for the following; toiletries, newspapers, dry cleaning , the hairdresser and private chiropody. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced key inspection on one day between 07.10 and 18.45 hours. Prior to the inspection a questionnaire was sent to the manager for completion to gain information, some of which has been included in this report. During the inspection I spoke to two staff and six service users’. I spent most of the inspection time in communal areas to observe daily routines and staff and service user interaction. I randomly looked at the premises, which included; the lounge and dining areas, four bedrooms, bathrooms, toilets, laundry and gardens. I looked at four service users’ case files to assess admission processes and care planning. I looked at three staff files to assess recruitment processes, supervision and training. I looked at medication management and safety and randomly checked records concerning maintenance and servicing of equipment. I indirectly observed breakfast time on the ground floor and lunch- time on the first floor. The manager was not available during the inspection however, the senior manager for the unit was present for part of the inspection. The senior team were the ones mostly involved in the inspection process. What the service does well: The home is owned and managed by Sandwell Council, which gives access to a wide range of advice and support networks. All bedrooms are single occupancy enhancing privacy and dignity. The home offers generous communal living space with both smoking and nonsmoking areas. Gardens are attractive and accessible. The home has a range of aids and adaptations to enhance service user safety, mobility and independence. The home has a warm, welcoming, friendly atmosphere. The home encourages service users’ to maintain contact with family and friends. It offers open, flexible, visiting times. The home is proactive in looking at ways to improve the service it provides. The home has developed good links with agencies that it works with to promote the health and well being of all service users’. Over half of the care staff team have achieved NVA level 2 or above in care. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 6 Service users’ that I spoke with made positive comments about the home as follows; “ It’s very nice”. “ Alright, been here for 3-4 years they look after me”. “ Very nice”. “ Comfortable everything we need”. “ The home is very nice”. What has improved since the last inspection? What they could do better: Medication systems and safety continues to be of concern. A number of shortfalls were identified which need to be addressed to prevent risk to service users. Although new care plan formats have been developed and new processes are being put into place some needs identified are not being sufficiently detailed such as; full health care needs and religion. The home must ensure that all incidence of aggression between service users’ are reported to the Commission as required by Regulation. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 7 A second sink in the laundry and hand wash signs in high-risk areas are lacking which decreases infection control within the home. Staff training needs to be made more widely accessible to ensure that all receive the required training such as infection control. 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. The summary of this inspection report can be made available in other formats on request. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4. Quality in this outcome area is good. Improvements in admission processes have been made since the last inspection to ensure that no service user moves into the home without having had their needs assessed and being given written assurance that their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: I spoke to six service users’ during the inspection. None of these service users’ told me they were unhappy or did not like the home. When I asked about their views on the home their responses included the following; “ It’s alright. Have been here for 3-4 years, they look after me”. “ Very nice”. “ The home is very nice”. I had a conversation with the management team and the senior manager for the home about terminology used for dementia care. The department describes this as ‘ Mental health’ which conflicts with the homes’ registration John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 10 which is for older people and people with dementia. ‘Mental Health’ under the Commissions categories of registration ( Mental Disorder) does not cover dementia care. The home must be careful to ensure that commissioners for the home are clear that the home does not provide care to people with a diagnosis of mental health. I must highlight however, that all files that I looked at confirmed that service users’ do in fact have a diagnosis of dementia not mental health. Information from a questionnaire completed by the manager told me that the home has made improvements to its admissions processes. The questionnaire told me; “ All new admissions are visited prior to their admission date by a member of the management team. In the cases where referral is late the admission is treated as a 72 hour review”. I looked at four service user files and saw that a terms and conditions document was on file for each confirming their rights during their stay. I saw on two of the four service users’ files a letter addressed to them from Sandwell finance department. This letter gave them a full breakdown of fees and the precise amount each had to pay themselves for their placement at the home. I also saw assessment of need information was on file together with information from each service users’ care management department. This is good as it demonstrates that the home obtains as much information about prospective service users’ before they are offered a placement to make sure that their needs can be met. I was please to see that a letter had been given to each service user confirming and giving each service user assurance that the home could meet their needs. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. Not all needs are set out in service users’ individual care plans. Evidence was lacking to confirm that service users’ and their relatives are involved in their care planning processes. Medication systems need further improvement to ensure that no service user is at risk. Service users’ are treated with politely and are shown respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service user files I looked contained a written care plan. New care plan formats are being introduced at the present time. The front sheet of these have pictorial symbols which, is good as this may increase understanding for those persons who have dementia or other conditions. The additional pages however, remain in writing only. It must be highlighted that these new care plans are in the implementation stage at the present time. However, I did see that some needs had not been included such as full information about religious needs and health care John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 12 information, which could potentially place service users’ at risk. For example; I saw that it had been recorded on one-service users’ care plan that they were Catholic, nothing else had been written. When I asked this person about their religion they told me; “ I’m a very religious person and would like to see a priest”. From speaking to staff it was clear that although a priest does visit the home this particular service user had not been given the opportunity to access this priest to date. Similarly, assessment information for another service user told me that they had been diagnosed as having ‘ blood pressure’, arthritis, and mini strokes. This information had not been transferred to the care plan. Therefore, staff do not have instruction on what to look for concerning these diagnoses or how to care for these conditions. I also noted when looking at care plans that there was very little evidence to show that individual service users’ or their relatives are being involved in the production of care plans. I was pleased to see that improvements have been made concerning the weighing of service users’. Records were available for all service users’ that I case tracked to confirm that they are being weighed on admission and regularly thereafter. I discussed the lack of processes in the home to assess tissue viability with the senior manager for the home. I explained that the Commission expected that processes to prevent tissue risk were in place. I was told that the department felt that this was a nursing task not one that should be done by the staff. I told this person that I found this interesting as the home carries out nutritional assessment and falls risks assessments, which the department could say, are Dietician and Occupational Therapists tasks. That tissue viability assessments are a risk preventative measure and a method by which staff are able to identify any problems or concerns at an early stage. I saw better records than I have done during previous inspections to confirm healthcare access. One file that I looked at confirmed that this person had been reviewed by a psychiatrist in July 2007. That they had been seen by the Community Psychiatric Nurse on 11.7.07 and had ,had their feet seen to by the chiropodist in January, April and July 2007. On another service users’ file I saw evidence to prove that she had the flu injection in December 2007 and had been seen by the dentist in January and March 2007. Service users’ that I spoke to confirmed that they receive adequate healthcare as follows; “ I see the doctor and chiropodist”. “ I see the doctor”. One staff member told me; “ Oh, yes they all get the care they need. Sometimes it’s difficult to get NHS chiropody but we get a private chiropodist for those who want to pay and most do”. Service users’ that I saw and spoke to during the inspection were clothes appropriately. Their hair was tidy. Their teeth and nails looked clean. One service user told me; “ They gave me a nice bath and washed my hair today”. Although better, I saw that there were a number of gaps on the daily personal John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 13 tick chart records. The senior manager told me that the department is looking to cease using this chart. In some areas medication management has improved examples being; staff who have responsibility for medications either have received or are in the process of receiving accredited medication training which is good as this can only improve medication safety in the home. I saw written evidence to confirm that staff are auditing medication management as issues were raised in the senior communication book which again is good as this will increase medication safety in the home as nonconformance will be identified and addressed. I did identify a number of shortfalls concerning medication safety which must be addressed to prevent risk to service users’. A number of these shortfalls were identified during previous inspections and have not to date been resolved in full. A selection of shortfalls that I identified is as follows; Not all prescribed preparations examples being creams and nutritional drinks are being signed for to confirm that they have been given. Medication packets are not being dated on the first day of usage and balances where medication is left over are not always being transferred onto the new medication record. These shortfalls make it very difficult for accurate audits to be carried out. I did identify from audits that I carried out that the totals remaining for three medications against balances were not correct. I saw that a photo was not available on three service users’ medication records as there should have been. The risk attached to this shortfall was higher because these medication records were all for new service users’ or service users’ who were at the home for a short stay. There is a higher chance that service identification could be mistaken for new or short stay service users’. This was addressed during the inspection. What had been happening was that one of the senior team who had responsibility for this task was developing the photos on her own computer at home, which understandably delayed the developing process. When the person in charge of the home on the inspection day heard about this she changed the process straight away by ordering the required materials to allow the photos to be developed on site which will be quicker. I was pleased to see that clear instructions for the medication Allendronic Acid were available on one service users’ file in order for this medication to be administered correctly. However, it appears that the process for these instructions to be available on all service users’ care plans who have been prescribed either this or similar preparations ( Risendronate) has ceased. Without these instructions it is likely that the medication has been administered incorrectly for example; at the same time as other medications, which could place the service users’ at risk. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 14 Care plans are not available for each service user to give staff an up to date list of current medications prescribed or allow an audit trial of when changes to medication have been made by the doctor. Care plans are not available for ‘ As required’ medications such as Lorazepam which means that staff do not have instruction on when this medication should be given. Where medication records are hand written there was no evidence to confirm that two staff check that the information written is correct. The allergy sections on medications records are not being completed to show allergies or no allergies. From observations it was clear that staff do treat the service users’ with respect and enhance dignity. All bedrooms are single occupancy, which promotes privacy. I saw that toilet and bathroom doors were closed when in use. I saw that the preferred name of each service user is determined and recorded on their personal file. I heard staff using these preferred forms of address for P and S. One service user told me; “ The staff are very polite”. During the inspection I saw staff encouraging service users’ to do things for themselves. Service users further confirmed that independence is encouraged; as follows; “ I like to try”. “ They let me do what I can for myself”. “ I do what I can for myself”. One issue I did raise with the senior manager was the lack of provision on the new care plans and documents to ask service users’ about preferences regarding the gender of staff providing their personal care. As this home has male and female staff it is important in terms of choice and dignity that this question s asked. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. The lifestyle experienced by service users’ generally matches their expectations and preferences. Visiting times are open and flexible. Service users’ are very much encouraged to maintain contact with family and friends. Meals offered are of an adequate standard and are nutritious. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From viewing records and speaking to service users’ it is clear that activity provision has improved since the last inspection. Although there were a few gaps activity records showed that something is offered most days and that staff do try to vary what is offered as follows; 29.6.07 gentle leg exercise. 14.7.07 Quiz, sing along to music. 15.7.07 Quiz. 17.7.07 gentle exercise. I spent time on ‘A Wing’ during the morning. Old ‘war time’ songs were playing. One service user was singing along happily. I looked at this service users file which said; ‘ Likes to listen to music’. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 16 When I went to the first floor I saw a service user knitting. She told me she likes to knit squares to make blankets. Another service user I spoke to told me that she; “ Reads magazines and books”. The staff told me that they do what they can regarding activities. Some days they can offer different things but if busy activity provision is limited. I discussed this with the senior manager. I suggested that activities would be improved upon and be more consistent if a dedicated activities co-ordinator were employed. When I arrived at the home only a small number of service users’ were up. I saw that the preferred rising and retiring times for the majority of service users’ has been determined and recorded. I asked a number of service users’ and two staff about daily routines and got the following answers; “ Oh yes, I can get up and go to bed when I want to”. “ Get up when I want to”. “ Get up when I want. Not made to get up early”. “ Oh, no. No one gets up unless they want to”. “ No set times for getting up or going to bed. In the mornings we put our heads around the doors to see if they want to get up, if not they stay where they are”. This evidence indicates that the home’s routines are arranged to meet the needs of the service users’ not the service, which is positive. Written information told me that visiting times are open and flexible. I asked service users’ I spoke to and they all confirmed that they have regular visitors. Information provided in the homes’ annual quality assurance assessment told me that ‘ Service users’ are given the facilities to see their visitors in private’ either in the home or their own room. Information about external advocates is available within the home for service users’ and their families to access if they want to. All bedrooms I viewed held a range of service user personal belongings such as pictures and ornaments making their rooms feel homely and personalised. The home should be congratulated as it has been awarded by external agencies a gold award for healthy eating and a silver ‘ five for life’ award. I saw throughout the home menus displayed, which have been produced in large print. The homes’ annual quality assurance questionnaire confirms that the manager is aware that these menus should be provided in pictorial formats to aid the understanding of service users’. I observed breakfast time on the ‘A wing’. I heard each service user being asked what they would like for their breakfast. I saw that a staff member fed one service user who was unable to feed herself. During the morning I heard staff offering service users’ drinks a number on times. I observed part of the meal- time on the first floor unit. The meal was attractively presented and smelt nice. I asked a number of service users’ and staff what they thought of the meals and was given the following answers; “ Sometimes nice”. “ Meals good and drinks. We can have what we want”. “ Very nice”. “ Meals? Cant remember , must be good”. “ Meals not up to scratch. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 17 Potato’s a bit hard. Can have choices”. “ “ Pretty good. Have choices. “ They like meat and two veg. Sometimes it’s chilli or something like that and they do not eat it”. The home is fortunate as it has access to dietary advice from a qualified person. The home’s annual quality assurance assessment told me that they home continues to make improvements where food is concerned for example; moulds have been purchased for soft diets to make the meals look more appetising. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is adequate. Although complaints procedures are available within the home they are not produced in formats other than writing, which does not enhance understanding. Although systems and procedures are in place to promote the protection of vulnerable people, these need further exploration to prevent incidents of aggression between service users’ and ensure that reporting follows each incident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes’ annual quality assurance assessment told me that ‘ no formal’ complaints have been received for some time. The Commissions data base and the home’s complaint firm confirms that this is correct. The home has a complaints procedure, which is available within the home. To date however, this has only been produced in writing not in pictures, which may aid understanding of people with dementia or confusion. I asked four service users’ what they would do if they had a complaint or were unhappy and got the following answers; “ I don’t know. I think I would just leave”. “ Don’t know what I would do”. “ Go to the management”. “ Speak to the staff”. This information shows that some work is needed to ensure that everyone is aware of what to do if they have a complaint. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 19 The home has processes in place aimed to protect vulnerable people. It is pleasing that the majority of staff have received abuse awareness training, which was evidenced by records and confirmed by records. A number of incidents have occurred between service users’ on the dementia unit. The night before the inspection on female service user had injured a male service users’ hand. Records about another incident read; 15.7.07 “.. attacked another service user”. Whilst it is positive that these incidents are generally reported to the relevant agencies. The incident that occurred on the 15.7 had not been reported to the Commission as it should have been. I asked service users’ if they had any concerns, if they had been shouted at, hit or anything else their responses were as follows; “ We are treated fine. No fighting, no nothing, am quite happy”. “ No, nothing like that. If there was I would be on to it”. “ No nothing like that”. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,26. Quality in this outcome area is good. Service users’ live in a safe and relatively well-maintained environment that meets their needs is comfortable, clean and homely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: John Dando is a large detached home that was purpose built, although this was some considerable years ago. Internally there are some redecoration needs examples of which include; the lounge on ‘A wing’ which needs paintwork redoing. Bedroom number 5 first floor that is also in need of redecoration as the paper is ripped in one area. The carpet also needs replacing as it has a hole just underneath the chest of drawers near to the window. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 21 The home does work to a redecorating programme and has had work done in the last year such as; the redecoration of the first floor lounge and the new carpet in there and alteration easier access to the garden from the A wing area. In the last week the drive has been repaired to make it safer. The senior on duty told me that the home has been given a sum of money which, it will be using in part for decorating purposes. The home has a lovely rear garden which is enclosed and level for safety. It is easily accessible from the ground floor and has a number of interesting features such as; raised beds and tree ornaments. The home has a number of different lounges and dining rooms. ‘A wing’ has a small area leading to the door to the garden that can be used for privacy. The home offers smoking and no smoking lounges for service user use. One service user told me; “ The living areas are adequate. I have a choice of different rooms”. I looked at four service users’ bedrooms ( Two showed me their own bedrooms). These were all comfortable and safe and fairly well equipped. I did not detect any odours. I asked service users’ what they thought about their bedrooms, they gave the following answers; “I like my bedroom. Look at all my things”. “ Like my bedroom”. From my observations I saw that the home was cleaner than during previous inspections and there was no unpleasant odour. I looked at bathrooms and toilets for infection control purposes. I saw that liquid soap, paper towels, gloves and aprons on rolls attached to wall dispensers were available which is positive. I did note that there was a lack of hand wash signs reminding people to wash their hands, which needs to be addressed to minimise the risk of infection transmission. I checked cleaning rotas in the laundry and found that although there were some gaps in records generally they were being completed more frequently. The home must address the issue of there only being one sink in the laundry as this does not provide a sink to be dedicated for staff hand wash purposes only which, could present an infection control risk. An additional laundry assistant has been employed since the previous inspection, which gives greater cover of duties in the laundry. I discussed with the senior on duty the need for staff to receive infection control training. She confirmed that the home is aware of this shortfall and is trying to secure accredited distance learning training on this subject. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. Assessment and exploration is needed to determine whether or not staffing levels are adequate at all times. Over 50 of the staff team have NVQ level 2 or above confirming that service users’ are in safe hands. Recruitments processes are sound. Induction processes are in place as they should be. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Generally staffing levels are provided as follows; AM ground floor 3 care staff AM first floor 3 staff until 11.30 am 2 after . PM 3 ground floor PM 2 first floor until 6.30 pm then 3. Nights 1 senior and 2 care staff. In addition seniors and the manager are on shift and the manager during business hours. Catering, cleaning and laundry staff are also provided everyday. I asked service users about staffing levels and was told the following; “ Enough staff”. “ Yes there are plenty”. “ We have been a bit short lately”.`” Sometimes no one, sometimes a lot”. “ Yes enough”. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 23 Staff told me that at times staffing is not always adequate especially if the unit is busy and there is only one senior or manager. Other comments from staff about staffing levels included the following; “ Three staff on nights enough”. “ Sometimes could do with a few more when it is ‘ bedlam’”. My observations on ‘ A wing’ revealed a number of occasions for some time when there was no staff present in the lounge. This may have been because one staff member had a funeral to attend in which case her duties should have been covered . During the times when there was no staff I noted that the service users’ showed signs of ill- being. They wandered and were agitated. I discussed my findings with the senior manager. I was told that the staffing levels of care staff and managers are being reviewed at the present time. Staff I observed were kind and friendly to the people in their care. I asked service users’ about the staff they told me; “ Everybody is nice”. “ I like the staff”. “ Staff are pretty good”. “ Oh, the staff are terrific”. “ Nice to medium”. “ I get on with the staff ”. Over 50 of the care staff team have achieved NVQ level 2 or above which means that the home is more than meeting the required 50 target. This means that the service users’ are in safe hands as to get this award staff have to be assessed as being competent to do their work. I looked at three staff files. From these I identified that recruitment processes are sound. The files held written applications forms, clarification of gaps in employment, written references and a memo confirming Criminal Bureau Record checks. I saw written evidence to confirm that one new staff had received induction training. I spoke to this staff member who told me; “ Yes I had induction training when I started”. A senior told me; “ We have a departmental induction programme which new staff attend over a two eek period”. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is good. The manager has been approved as a fit person to run and manage the home. Quality monitoring processes are in place, which are externally accredited. Systems are in place to safeguard service user money. More attention must be paid to staff supervision to ensure that all receive to the required frequency. Generally, health and safety within the home is well promoted and managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission as a fit person to run and manage the home has approved the manager since the last inspection. She has the required qualifications and is not responsible for any other registered premises. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 25 Sine the last inspection the home has been reaccredited with ISOQAR concerning its quality assurance system. The senior on duty told me that the home is behind with some of it’s internal audits but is in the process of addressing this. The home uses a range of methods to ensure that service user views are gained in order for satisfaction or other to be monitored including six monthly in-house reviews and service user meetings. The home has good systems in place for safeguarding service user money. Money is held in individual sealed envelopes in a safe. The safe content is checked at the start and end of every shift. I checked the money of the four service users’ that I case tracked. One did not have any money held in safekeeping by the home. The other three did. I checked their money against balances and found this to be correct. I saw that two signatures confirmed each transaction and that receipts for money spent were available. The senior team on duty told me that they are aware that staff supervisions are not being carried out to the required frequency of six times per year per staff member but this is being addressed. I looked at records for the kitchen and saw that fridge, freezer and hot food temperatures are being taken and recorded. I checked three catering staff files which told me that they have all received food hygiene training within the last 12 months. Environmental health carried out an inspection of the kitchen twelve months ago. Only three recommendations were made. The senior team confirmed that some staff’s mandatory training is not fully up to date. They told me that they are nominating the staff for training but are not being given places. Specific training areas that are lacking are first aid, food hygiene and moving and handling. I looked at fire drill records and saw that the number of staff who have been involved in these fire drills does not add up to the total staffing numbers for the home which means that some staff have not received recent fore drill training. I looked at the monthly accident analysis figures. Some months the incidence of accidents or incidents were high however recently the incidences have been less; 2007 Jan 11, Feb 17, March 23, April 30, May 21, June 13. I randomly checked service certificates and evidence of in-house checks concerning equipment and supplies as follows; 5 Year fixed electrical wiring test not due until 2009. Hot water temperatures had been tested in June and July 2007. An approved person checked the gas appliances in June 2007. The hoists were serviced in April 2007. The passenger lift was serviced in March 2007. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 26 I did note that hot pipe work is still exposed in the toilets opposite room 8 on ‘A wing’. This needs to be addressed to prevent risk to the service users’. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 3 x x x 3 x 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 3 John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement Care plans must be thoroughly completed to reflect all needs and wants for example; religious needs and safety and health conditions. This requirement has been made to ensure that the needs of all service users are met and that they are safe. The registered provider and manager must ensure that all prescribed topical preparations are signed for after application. Timescales of 20/07/05, 25/03/06 and 30/08/06 not fully met. 3 OP9 13(2) The registered provider and manager must ensure that written evidence is available at all times to show that prescribed dietary supplements have been given. Timescale of 30/09/07 not met. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 29 Timescale for action 30/08/07 2 OP9 13(2) 15/08/07 15/08/07 .4 OP9 13(2) The registered provider and manager must provide a minimum and maximum thermometer in the medication room. Daily temperature readings must be taken and recorded. Timescales of 01/04/06 and 30/09/07 not fully met. The registered provider and manager must ensure that where a choice of dosage is given for example ‘ one tablet or two’ the number of tablets actually given must be written on the medication record. Timescale of 27/03/06 and 30/09/07 not fully met. The registered provider and manager must ensure that a medication care plan is in place for each resident who has medication prescribed on an‘ as needed’ basis for example Haloperidol ( and Lorazepam). This to give instructions to staff in what circumstances the medication should be given. Timescale of 30/09/07 not met. All medications must be counted and recorded when received. Any balances must be forwarded onto new medication records. Medication boxes and packets must be date labelled when first used to allow effective audit. This requirement has been made to increase medication safety in the home and to prevent risks to service users’. 15/08/07 5 OP9 13(2) 13/08/07 6 OP9 13(2) 13/08/07 7 OP9 13(2) 15/08/07 John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 30 8 OP26 13(3) The registered provider and manager must ensure that: Hand wash signs in appropriate formats are displayed in all toilets, bathrooms and other high-risk areas. Timescales of 27/03/06 and 01/10/06 not met. 01/09/07 9 OP26 13(3) The registered provider and manager must install a sink in the laundry for the sole purpose of staff hand washing. The registered provider and manager must ensure that all staff receive fire drill instruction twice in any 12-month period. Timescales of 01/08/05, 01/04/06 and 01/11/07 not fully met. 01/11/07 10 OP38 23(4) 01/11/07 11 OP38 13(4)( c) The registered provider and manager must ensure that all exposed hot water pipes in bathrooms and toilets are suitably guarded. ( For example opposite room 8 A wing). Timescale of 01/10/07 not fully met. 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Care plans should be produced in full formats appropriate to the needs of the service users, large print pictorial. DS0000034187.V341668.R01.S.doc Version 5.2 Page 31 John Dando Residential Centre 2 OP7 3 4 5 OP8 OP8 OP9 6 7 OP9 OP10 8 OP12 9 OP16 10 11 12 13 14 OP18 OP26 OP27 OP36 OP38 All service users and/ or their representatives are consulted with in respect of their care plan and any subsequent reviews and that there is provision on the care plan for them to sign. Daily care (tick) charts should be fully maintained at all times. All staff should receive in-depth dementia trainingpreferably of an accredited type. This also applies to night and casual staff. The registered provider and manager must ensure that where medication records are hand written the information being transferred from medication containers is verified as correct by two staff. Medication records should detail any allergies or no allergies. Each service user should be consulted with about their choices re; gender of the staff providing their personal care. The outcomes of this consultation should be recorded and acted upon. A suitably qualified / dedicated activities person should be employed. Individual activity/ stimulation needs should be determined for each service user and included in their care plan. Complaints procedures should be produced in formats suitable for the needs of service users to ensure that as many as possible fully understand and know what to do if they are unhappy or who to complain to. All concerns or incidence of aggression between service users should be reported to the CSCI. All staff should receive infection control training. Staffing levels should be monitored and reassessed to ensure adequate this to include all levels of staff and weekends. All staff should receive six supervision sessions in any 12month period. All staff should receive training in first aid, moving and handling (including hoist training) health and safety, fire training and food hygiene. John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 32 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 John Dando Residential Centre DS0000034187.V341668.R01.S.doc Version 5.2 Page 33 - 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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