Inspection on 27/02/06 for John Dando Residential Centre

This inspection was carried out on 27th February 2006.

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

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

Other inspections for this house

John Dando Residential Centre 23/07/07

John Dando Residential Centre 29/08/06

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 Unannounced Inspection 27th February 2006 07:15 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.V283716.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 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 351 9425 Sandwell Metropolitan Borough Council Mrs Beverley Hellend 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.V283716.R01.S.doc Version 5.1 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. 04/07/05 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 owned and managed by Sandwell Council. The home 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 comprises of two floors. Internally the home is divided into four units three on the ground floor and one on the first. All of the units have their own assisted bathroom, toilets, kitchenette, dining and living space. The home has a main kitchen where the meals are prepared and one main laundry. 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. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.15 and 18.05 hours. The inspection was the second of the homes two routine inspections for this inspection year. The inspection focused on core National Minimum Standards for Older People that were not assessed during the last inspection and previous requirements made. During the course of the inspection the premises were randomly assessed in terms of infection control prevention, décor and fabric. Four staff and 12 residents’ were spoken to. Three senior staff and the manager were involved in the inspection process. Three staff and four resident files were examined. Meal times were observed and the main kitchen assessed. Medication administration was observed, stock and records checked. Maintenance and staff training certificates were examined. Not all standards were assessed during this inspection. For a full overview of service delivery this report should be read together with the last inspection report dated 4 July 2005. What the service does well: The home is owned and managed by Sandwell Council providing support and advice from senior managers and other specialists. The homes’ atmosphere is warm, friendly, positive and welcoming. A number of senior and other staff at the home have worked there for some considerable time providing consistency and stability to the residents. Management and staff spoken to or observed strive to provide a good standard of care to the residents and are keen to improve the home wherever they can. All bedrooms are single occupancy promoting privacy and dignity. The garden is of a generous size, is safe, well maintained, accessible and suitable for the residents’ accommodated. The home offers open, flexible visiting times and positively encourages residents to maintain contact with family and friends. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 6 Meals provided within the home are of a good standard, interesting and varied. Mealtimes observed were relaxed and positive. The home is fortunate as it has access to a dietician employed by the organisation. The home has robust processes in place to ensure residents’ money held by the home is safe and accounted for. Positive comments were made by both staff and residents. One staff member said; ”I like working at the home”. Another commented;” I like it here. Particularly working with people with dementia. We work well as a team”. Residents comments included the following;” I Can not say I don’t like living here, I do. The staff generally are nice.” “ Here? It’s alright. So far so good”. “ The staff are good. I have no complaints”. What has improved since the last inspection? Senior management have approved finance to have the required two double electrical sockets provided in each bedroom. A number of bedroom floorings have been replaced. Redecoration work is being carried out on the first floor. New carpets, curtains and furniture have been ordered for this area. New, more effective lighting has been fitted on the first floor. When the first floor is completed the acting manager confirmed that redecoration will commence in the ground floor units. Overall the utilisation of agency staff has decreased. The home has 4 casual staff delegated to the home improving consistency and familiarity. Nine staff have been appointed, the manager is awaiting the required checks and documents before these prospective staff can commence employment. Medication systems have improved in some areas (but need further improvement in others). Catering staff have all now received the required food hygiene refresher training. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 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.V283716.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 Residents and their representatives are informed that the home they enter will met their needs. EVIDENCE: It is positive that the acting manager contacted the CSCI in February 2006 when she was concerned that the home could not meet the needs of a prospective resident who had been referred. After discussion the acting manager informed the referrer that the home would not be able to accept the prospective resident and gave an explanation why. This situation confirms that the acting manager is well aware of her responsibilities in relation to the homes categories of registration. Evidence in the form of a letter was available on residents files proving that the home confirms to all prospective/new residents that their needs can/will be met. The home has acted correctly in the past as they applied for a variation to their registration to accommodate a resident, as a condition, who had physical disability needs. This situation has now changed as the resident has since moved to a nursing home an application to have the category removed is now needed. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,10. Residents health, personal and social care needs are not sufficiently set out in their individual care plans. Medication systems require further improvement to ensure that they are safe and effective. Generally, residents’ feel they are treated with respect and their privacy is upheld. EVIDENCE: Although improvements have been made to care plans, for example increased information, more improvement is needed. It is disappointing however, that there was no care plan in place for one new resident even though he had been accommodated for nearly 2 weeks. Information contained within the care plans in general is ‘the problem or goal’, they still lack the required management and specific instruction. There is little evidence to suggest that residents’ or their relatives are involved in the care planning and review processes. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 11 Medication systems, again although improved, require further diligence and improvement. It was pleasing to see that the home since the last inspection has established a robust system in respect of obtaining and retaining ‘ patient information’ leaflets that are issued with individual\medications. ‘Core’ care plans have been developed and have been placed on residents files. Specific instructions regarding individual medications have been also placed on residents’ files where needed. There was no evidence available to demonstrate that medication training proposed for the future has been discussed with the CSCI pharmacist to confirm validity. It was disappointing that initial gaps are still occurring on medication records. It was noted that in some instances medication records had been handwritten, there was no evidence however, to confirm that the handwritten instructions had been verified as correct by 2 staff top prevent errors. It was noted that where medication for example tablets have been prescribed, as ‘one or two’ staff are not entering how many have actually been given. Topical prescribed preparations are not always been signed for after application. One residents’ medication record stated ‘DN’- which implied that the district nurse was applying the preparation. The staff however, felt that this was unlikely and there were no initials on the records to confirm this. It is positive that a number of residents spoken to confirmed that they were treated well by the staff and that they were able to have privacy when they wanted to. One resident said; “ The staff are courteous and polite”. Another said; “The staff are kind, caring and never get cross”. One resident commented,” the staff are alright - polite”. Observations of staff/resident interaction was positive. Staff giving residents’ choices and encouraging them to say what they wanted to. Staff observed were polite and respectful when speaking to the residents’. Residents’ records demonstrated that they are asked on admission their preferred form of address and their view in relation to opposite gender staff providing their personal care. All bedrooms are single occupancy enhancing dignity and privacy. Toilet and bathroom doors are fitted with lockable facilities. Observations confirmed that staff ensure that toilet and bathroom doors are closed when these rooms are in use. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,15. The home actively encourages residents to maintain contact with family and friends. Residents’ receive a wholesome appealing diet in pleasing surroundings. EVIDENCE: The home has open visiting arrangements. The homes’ statement of purpose’ pack includes a ‘ Residential services family and friends policy’. This policy states; “ ..families and friends are welcome to visit at any time, however, we would appreciate that mealtimes be avoided wherever possible”. One resident said;” My family all come and see me”. The home has a set menu operating on a cycle over a number of weeks. The menus are interesting and varied. Choices are available at all mealtimes. It is positive that four meals per day, breakfast, lunch, tea and supper are detailed on the menu. The home is fortunate as it has access to a dietician employed by the organisation who is involved in the production of the menus. The home has achieved healthy eating awards for example; ‘ Five for Life’. Healthy options are available at all times. In collaboration with the dietician the home offers build up drinks and ‘smoothies’ to increase nutritional and calorific John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 13 intake for those who need this. It was noted however, that the ‘smoothie’ list available had not been updated for some time as it should. It was also noted although positive in that these records are being maintained, the food consumption records with numerous names on each sheet are not data protection or access to records compliant. Additionally, supper is not included on these records as it should be. Mealtimes were observed. At the time of the inspection the first floor of the home was being redecorated. Residents from this floor having to utilise the main dining room for meals on the ground floor. Residents accommodated on the ground floor were not affected by this redecoration and were able to have their meals in their unit dining areas. Mealtimes were relaxed. The surroundings pleasant and fit for purpose. Tables were nicely laid with condiments available. Staff were on hand to give assistance. Breakfast time a range of cereals to include porridge were offered along with hot or cold milk. Residents’ also had the choice of toast or scrambled egg and toast or bread. Lunch consisted of boiled ham or breaded fish. The meals were nicely presented, of a good standard and were of a generous size. Observations revealed that the residents’ enjoyed their food and there was little waste. One resident said; ”The food is good. There is plenty of choice”. Another commented;” The food is good. There is a choice at every meal”. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Nil No standards in this section were assessed during this inspection. EVIDENCE: No standards in this section were assessed during this inspection. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26. Further attention is needed to ensure that the residents live in a well maintained environment. Further developments are needed to ensure that the home is safe, comfortable and hygienic. EVIDENCE: The home is a large detached building separated internally into four separate units. The ground floor smaller units cater for residents who have dementia. These units are symbolised to aid understanding and orientation. One resident spoken to said;” I think the home is alright. It has enough lounges and toilets”. The home requires considerable redecoration work. This mainly concerns paintwork in toilets, bathrooms, communal/living areas and bedrooms. It is positive that the acting manager has undertaken an audit of the premises and is aware of the work required. She has worked hard to secure the needed finances to cover refurbishment work, this to include the fitting of the required John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 16 two double electrical sockets in the bedrooms. Work has commenced on the first floor living areas which are being redecorated at the present time. A number of bedrooms have had new laminate style flooring fitted to maximise hygiene and reduce the incidence of odour. New carpets, curtains and furniture have been ordered for first floor rooms. The home has a garden area to the front and rear. The rear garden is completely enclosed, is accessible and safe for all residents to use. The garden has been designed to enhance safety and orientation by using pathways and other features. The garden is of a good standard and is valuable to the people who live at the home particularly in the spring and summer months. It was noted that water pipes in ground floor toilets and bathrooms are not all guarded posing a potential risk to the residents. It is concerning that water coming from the tap outlets in this area felt ‘ luke warm’ certainly not within the range of 38oc-43oc. The water was left to run for some time, this did not however, make any difference. Even if it had, the majority residents’ are unlikely to wait when washing their hands for the water to run hot. This situation presents as a possible infection contamination risk. It was noted that ventilation systems in bathrooms and toilets on the ground floor were not functioning as they should. It is positive that radiators seen throughout the home were all guarded. It is positive that the home has a mechanical disinfector for the cleaning of commode pots. Infection control throughout the home requires attention and greater diligence. Requirements made previously in relation to cleaning schedules and mop management have not been fully met. Not all staff have received infection control training and there was no evidence internally of infection control audits. Communal items examples being; bar soap and a bath sponge were seen in two bathrooms. Piles of clean towels were stored in one bathroom, again presenting as a infection contamination risk. There is a lack of ‘hand wash’ signs in bathrooms, toilets and other high risk areas to remind residents and others to wash their hands after attending to personal needs to prevent cross infection. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,30. A greater level of N.V.Q attainment is needed to ensure that residents’ are in safe hands at all times. Generally staff are trained and competent to do their jobs. EVIDENCE: Nineteen of the thirty-six care staff employed have NVQ level 2 in care or above. Whilst this is very encouraging these figures at the present time do not equate to the required 50 of staff at any one time having this qualification. Evidence was available to demonstrate that staff are receiving in-house induction and a two week corporate induction package which meets the required specifications. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Confirmation by registration processes is required to ensure that the home is being run by a person fit to be in charge. Quality assurance/monitoring processes require more attention. Residents’ financial interests are safeguarded. Confirmation and greater attention is needed in respect of health and safety. EVIDENCE: The registered manager has been on secondment in another post for some time. An acting manager has been in post at least for the last 8 months. A decision is needed to determine if the registered manager will be returning to the home by April 2006 otherwise the organisation most forward an application for the acting manager (or other person) to be considered for registration. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 19 It is positive that the acting service manager visits the home regularly and produces a written report of her findings, a copy of which is sent to the Commission for perusal. There was a lack of evidence to demonstrate that the views of residents’, relatives and other stakeholders are being sought regularly or results from surveys are being published. The acting manager and senior staff suggested that the auditing and monitoring of quality systems are not as ‘ up to date’ as they should be. It is positive that robust systems are in operation to safeguard residents’ money held in ‘safekeeping’ by the home. Each residents’ money is held in a separate envelope with their name and the amount contained detailed. Balance sheets for each resident are used to record all deposits and transactions. Two people sign to verify all transactions. The contents of the safe is checked at the end/start of each shift. The manager audits the safe content and individual resident balance sheets regularly. It was also positive to see that each residents’ belongings are recorded on a personal inventory on admission however, an on-going shortfall in respect of this is the lack of furniture being recorded. Records pertaining to health and safety and maintenance were examined. Generally these were maintained and up to date for example, the fire alarm system was serviced in December 2005, the extinguishers were serviced in Feb 06, electrical appliance testing was carried out in July 05. Confirmation/ improvement in respect of some areas is needed. For example the 5 year fixed electrical wiring test highlighted work required, there is not however, any written confirmation that this work has been completed. Refurbishment work on the lift has been highlighted on at least the last 3 reports yet, there is no evidence to confirm that this work has been attended to. There was no gas landlords certificate available. The team leader discussed new fire training. It is surprising that she who is to deliver the training has not yet received any formal training herself. It was noted as with the previous inspection that not all staff have received the required fire drill in the last 12 months. Mandatory training is lacking in some areas, this confirmed by the team leader and must be addressed as a matter of urgency. One staff member was observed during the inspection using a wheelchair with only one footrest. One resident (HG) was observed mobilising in slippers that were far too big for him presenting as a potential tripping hazard. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 x x x x x 2 2 STAFFING Standard No Score 27 x 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 21 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 OP2 Regulation 5(1)(b) Requirement The registered provider and manager must ensure that residents’ terms and condition documents detail the following; Who is responsible for paying the fee. Who is liable if a breach occurs. Timescale of 04/08/05 not fully met. The manager said that a new terms and conditions document is being produced. In the interim period a document has been produced to detail current fees. 2 OP3 14(1)(a) (b)(c) The registered provider and 01/04/06 manager must ensure that a thorough and robust assessment of need process is developed and implemented with accompanying documentation. The process must include all main areas of care, standard 3 could be used as a template. John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 22 Timescale for action 01/05/06 The outcome of this assessment must detail a list of needs including the primary need examples being dementia, old age etc. Evidence must be available to demonstrate that the prospective resident/and or his relative have been involved in the assessment of need process and that they agree with the needs identified. This could be done by them signing and dating the assessment of need form/documentation. The registered provider must ensure that a documented assessment of need be carried out for each prospective service users. Timescales of 09/11/04 and 04/08/05 not met. There was no evidence of assessment of need processes in respect of two residents highlighted during the inspection who had recently been admitted. 3 OP4 14(1) The registered provider and manager must apply to the CSCI to have the condition of PD removed in respect of former resident ( VS). The registered provider and manager must ensure that a care plan is produced for each resident accommodated within an acceptable time period, preferably at the time of admission. No care plan was in operation for resident (JC). 01/04/06 4 OP7 15(1) 27/03/06 John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 23 5 OP7 15(1) 15(2)(b) The registered provider and manager must ensure that (H.G) care plan states what must be done, when, how, how often and by who. Timescale of 04/07/05 not fully met. This shortfall was subject to a serious concern letter being issued following the last inspection. The care plans mostly states what the problems are and do not give sufficient management instruction. 01/04/06 6 OP7 15(1) 15(2)(b) The registered provider and manager must ensure that care plans cover all initial assessed needs, diagnosis, the full spectrum of activities of daily living. 01/04/06 7 OP7 15(1) 15(2c) 13(4c) The registered provider and manager must ensure that all residents and or their representatives are consulted with in respect of their care plan and any subsequent reviews. Timescale of 12/07/05 not fully met. 01/04/06 8 OP8 12(1)(a) (b) 17(2) The registered provider and manager must ensure that the care (tick) charts are maintained at all times. DS0000034187.V283716.R01.S.doc 01/04/06 John Dando Residential Centre Version 5.1 Page 24 Timescale of 20/11/05 not fully met. (JC not completed since 21/2/06. KA not completed since 23/2/06). 9 OP8 12(1(a)b) 18(1)(a) The registered provider and manager must ensure that all staff receive in-depth dementia training- preferably of an accredited type. The registered provider and manager must ensure that a documented tissue viability assessment process is developed and implemented. This must be carried out for each resident on admission and regularly thereafter depending on need. Timescale of 20/07/06 not met. The registered provider and manager must ensure that medication is signed for at the point of administration. Timescale of 04/07/05 not fully met. 01/06/06 10 OP8 12(1(a(b) 13(4(c) 01/04/06 11 OP9 13(2) 25/03/06 12 OP9 13(2) The registered provider and manager must ensure that where medications ( this does not apply to ‘As required’ medication) are refused for longer than 3 days that the residents’ doctor is informed. It would be expedient for the doctor to be informed sooner than this for medications such as steroids, heart regulators or anti-coagulants). DS0000034187.V283716.R01.S.doc 25/03/05 John Dando Residential Centre Version 5.1 Page 25 Timescale of 15/07/05 not fully met. 13 OP9 13(2) The registered provider and manager must ensure that an approved pharmacy guide, for example, BNF, that is not over 12 months old is available at all times. Timescale of 20/07/06 not met. 14 OP9 13(2) The registered provider and manager must ensure that all prescribed topical preparations are signed for after application. Timescale of 20/07/05 not met. 25/03/06 01/04/06 15 OP9 13(2) The registered provider and 01/04/06 manager must identify who wrote D/N on the medication record for a topical preparation and determine why this prescribed preparation is not being signed for. The outcome of this investigation and the action taken must be provided to the CSCI. 16 OP9 13(2) 17 OP9 13(2) The registered provider and manager must ensure that all staff are formally reminded not to leave the unlocked medication trolley unattended. The registered provider and manager must ensure; DS0000034187.V283716.R01.S.doc 25/03/06 27/03/06 John Dando Residential Centre Version 5.1 Page 26 That a copy of the medication procedure is available at all times. 18 OP9 13(2) The registered provider and manager must ensure that all staff who have responsibility for medications receive adequate medication training. The manager must consult with the CSCI pharmacy inspector to determine suitable training. 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. And That the level of detail on the records is the same as preprinted medication records examples being allergies/ doctors name. 20 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. 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. 01/04/06 01/05/06 19 OP9 13(2) 25/03/06 21 OP9 13(2) 27/03/06 John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 27 22 OP9 13(2) 23 OP12 16(2)(n) 18(1)(a) The registered manager must on a monthly basis audit medications being returned to the chemist to identify any high level of non-administration. The registered provider and manager must employ a suitably qualified / dedicated activities person. The registered provider and manager must ensure that activities are provided on a regular basis and that records are maintained of individual activity participation. Timescale of 20/07/05 not fully met. 27/03/06 01/06/06 24 OP12 16(2)(m) (n) 01/04/06 25 OP12 16(2) The registered provider and manager must ensure that individual activity /stimulation needs are determined for each resident and included in their care plan. Timescale of 01/08/05 not fully met. 27/03/06 26 OP18 17(2) Sch 4 (10) The registered provider and manager must ensure that all items of furniture brought into the home by residents’ are included in their personal inventory. Timescale of 01/08/05 not fully met. 01/04/06 27 OP15 17(2) Sch 4 (13) The registered provider and manager must ensure that; Food consumption records are maintained to the individual resident. 01/04/06 John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 28 Supper is added to the food consumption records. 28 OP16 22(2) The registered provider and manager must produce a complaints procedure in an additional format, for example, pictorial , to aid the understanding of service users who have a diagnosis of dementia. Timescales of 05/01/05 and 01/08/05 not met. The registered provider and manager must ensure that the name, address and telephone number of the Commission for Social Care Inspection is detailed on all complaints leaflets/information. Timescale of 20/08/05 not fully met. 30 OP18 13(6) The registered provider and manager must ensure that all incidents of abuse between residents is reported as per Sandwell Councils’ adult protection procedures. The incident highlighted during the inspection, that occurred in December 2005 ( between C and GB) must be reported retrospectively . 25/03/06 01/04/06 29 OP16 22(7)(a) 01/04/06 31 OP18 13(6) The registered provider and 01/04/06 manager must ensure that all policies and procedures relating to adult protection are up to date and current. That staff read, sign and date John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 29 32 OP18 13(6) these procedures. The registered provider and manager must adapt the drafted restraint/ physical intervention policies to ensure that they are appropriate for John Dando. This policy must then be finalised and be put into operation. Timescales of 10/12/04 and 01/09/05 not met. 01/04/06 33 OP24 23(2)(f) The registered provider and manager must ensure that all of the service users bedrooms are equipped with two double electrical sockets. Timescales of 10/12/04 and 01/09/05 not met. It is positive in that money has been allocated in order for this requirement to be met. 01/05/06 34 OP24 16(2)(c) 23(2)(f) The registered person must ensure that an audit is carried out on each residents’ bedroom against standard 24. All items must be provided if required by the resident. If they state they do not want certain items then this must be recorded. Timescale of 01/09/05 not met. The registered provider and manager must ensure that hot water is provided from each outlet is maintained within the range of 38oc-43oc at all times and that there is no undue delay in the water getting sufficiently hot. The registered provider and manager must ensure that all DS0000034187.V283716.R01.S.doc 01/04/06 35 OP25 23(2)(j) 01/04/06 36 OP25 13(4) 01/05/06 Page 30 John Dando Residential Centre Version 5.1 37 OP25 23(2)(p) exposed hot water pipes in bathrooms and toilets are suitably guarded. The registered provider and manager must ensure that all ventilation systems in toilets and bathrooms are in good working order at all times and that they are switched on. 01/04/06 38 OP26 23(2)(d) The registered provider and manager must ensure that the cleaning schedule is consistently adhered to. Timescale of 20/07/05 not fully met. 01/04/06 39 OP26 13(3) The registered provider and manager must ensure that all mops are cleaned to disinfectant temperatures daily and that they are left to dry when not in use. Dates must be recorded each time mop heads are replaced. Timescale of 20/07/05 not met. 27/03/06 40 OP26 13(3) 18(1)(a) The registered provider and manager must ensure that all staff receive infection control training. The registered provider and manager must ensure that: Bar soap is not provided for communal use in toilets and bathrooms. Bath sponges and other personal care items are used for individual residents only and are returned 01/07/06 41 OP26 13(3) 27/03/06 John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 31 to their rooms after use. Stocks of clean material towels are not stored in bathrooms or toilets. Hand wash signs in appropriate formats are displayed in all toilets, bathrooms and other high risk areas. The registered provider and 01/04/06 manager must ensure that a suitably qualified member of the team is delegated responsibility in the home for infection control. This person must then carryout regular documented infection control audits. The registered provider and 01/04/06 manager must ensure that all information relating to the recruitment of staff (plus all information detailed in Schedules 2 and 4) is held on site. This to include the following; Application form. Interview questions and answers. Two written references one from the last employer. Health declaration. Evidence that General Social Care Council codes of conduct and practice have been issued. Original enhanced CRB/POVA list check. Timescale of 04/08/05 not met. 44 OP31 8,9. The registered provider must DS0000034187.V283716.R01.S.doc 42 OP26 13(3) 43 OP29 13(6) 19(2) 01/04/06 Page 32 John Dando Residential Centre Version 5.1 45 OP33 24 either; Confirm in writing that the registered manager will be returning to her post of manager or nominate a suitably qualified and competent person to apply for registration of manager at John Dando. If the latter is chosen a completed application form must be forwarded to the CSCI. The registered provider and manager must ensure that; Quality monitoring processes are in place to determine feedback from residents’ relatives and other stakeholders and that the results from these are published. Audits of procedures and practices are conducted regularly. All policies and procedures are available for staff to read. 01/05/06 46 OP36 18(2) The registered provider and 01/04/06 manager must ensure that all staff receive six supervision sessions in any 12-month period. A staff supervision matrix must be produced. Timescale of 01/08/05 not fully met. 47 OP37 17(2) 18(1)(a) The registered provider and manager must ensure that all staff receive care planning and record keeping training. Timescale of 28/08/05 not met. 01/04/06 48 OP37 17(2) The registered provider and DS0000034187.V283716.R01.S.doc 01/05/06 Version 5.1 Page 33 John Dando Residential Centre manager must ensure that all staff read, date and sign the homes policies and procedures. Timescales of 10/12/04 and 01/08/05 not fully met. The registered provider and manager must ensure that all staff (who have not within the required timescales) receive training in first aid, moving and handling (including hoist training) health and safety, fire training and food hygiene. Timescales of 10/12/04 and 20/08/05 not fully met. 50 OP38 23(4) The registered provider and manager must ensure that all staff receive fire drill instruction twice in any 12 month period. Timescale of 01/08/05 not fully met. 51 OP38 13(4) 23(2)(c) The registered provider and manager must request written confirmation from suitably qualified persons that: Work highlighted in respect of the assisted bath has been completed and is in good working order. Work highlighted on the last lift engineer report has been addressed and is in good working order. Work highlighted in the last 5 year fixed electrical wiring test has been completed and is in safe working order. 01/04/06 01/04/06 49 OP38 13(4(5) 18(1a) 23(4) 01/05/06 John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 34 52 OP38 13(4) 23(2)(c) These confirmations must be forwarded to the CSCI. The registered provider and manager must ensure that footrests are used on wheelchairs at all times. 25/03/06 53 OP38 13(4) 23(4) 23(4) 54 OP38 55 OP38 13(4) The registered provider and manager must ensure that a gas landlords certificate is available at all times. The registered provider and manager must seek written confirmation from West Midlands Fire Service stating that the proposed fire training is adequate and whether or not the trainer needs the West Midlands Fire Service course. A copy of this confirmation must be forwarded to the CSCI. The registered provider and manager must ensure that risk assessments and action is taken in respect of (HG’s) footwear which could pose a tripping hazard. This concern was highlighted to the manager and staff during the inspection. 20/06/06 01/04/06 27/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 35 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. Extracts may not be used or reproduced without the express permission of CSCI John Dando Residential Centre DS0000034187.V283716.R01.S.doc Version 5.1 Page 36 - 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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