Inspection on 29/08/06 for John Dando Residential Centre

This inspection was carried out on 29th August 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 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 Unannounced Inspection 29th August 2006 07:25 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.V308548.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.V308548.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 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.V308548.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. 27/02/06 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 £94.45 (respite) to £467 per week. Additional charges apply for the following; toiletries, newspapers, dry cleaning , the hairdresser and private chiropody. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 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 07.25 and 18.25 hours. The inspection process assessed all of the key National Minimum Standards for older people. To aid the inspection process a number of questionnaires were forwarded to the home for completion before the inspection. A proportion of the inspection was conducted in the living areas where care practices and staff/resident interaction could be observed. During the course of the inspection four residents’ files to include assessment of need and care plan documents were assessed. Three staff files to include recruitment documents and training were also assessed. The premises were part assessed to include the lounge/dining rooms on two units, three bedrooms, the laundry, kitchen, garden, bathrooms and toilets. Medication systems and the safe keeping of resident money were assessed. The lunch time on D wing unit was observed. Ten residents and five staff were spoken to during the inspection. The manager was on site during the inspection. 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 have worked at the home for some considerable time providing consistency and stability to the residents. Management and staff continue to strive to provide a good service to the residents in their care. They are keen to improve areas where shortfalls exist. All bedrooms are single occupancy promoting privacy and dignity. The garden is of a generous size, is safe, attractive, 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. Meals provided within the home are interesting and varied. The home has achieved a number of ‘Healthy Eating’ awards. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 6 Positive comments were received about the home from both residents’ and staff which included the following; “ We try hard to give the best care. Everybody seems to want to provide a good standard of care. The staff are very caring”. “ I love my job”. “ We have a good crew here we work hard”. “ I like it here”. “ The staff are very good”. “No concerns I am very satisfied”. “I have settled in lovely. I like it”. “ I am very happy and contented here”. “The staff are very nice”. What has improved since the last inspection? What they could do better: The home must continue to improve in respect of assessment of need, care planning and general record keeping. This particularly applies to residents’ who are admitted to the home for short-term care. Medication systems although improvements have been made need further improvement to ensure safety. Staff need to receive accredited medication training. Activity provision within the home needs to be improved in terms of choice and regularity. Adult protection processes require fine-tuning in order to prevent risk to residents’. Records and information available for example complaints procedures must be produced in a format which can be easier to understand by those residents’ with a diagnosis of dementia for example a pictorial version. Infection control processes require more attention to prevent risk to residents’. Evidence must be available on site to prove that the required checks have been carried out for new staff. Staff supervision processes and not adequate in terms of frequency at the present time. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 7 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.V308548.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.V308548.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4. The overall outcome for this group of standards is judged to be poor. Not all residents’ are being issued with a terms and conditions document. The weekly fee rate on terms and condition documents seen do not apply to this financial year. Assessment of need processes. particularly for residents accessing short-term care are poor with no documentation available. There was no evidence to confirm that written acknowledgement is given to residents’ assuring them that the home can meet their needs. EVIDENCE: It is positive that eight of the eight completed resident questionnaires received confirmed that they had been given enough information before they had been admitted to enable them to make the decision that the home would be suitable for them. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 10 It is also positive that seven of the eight completed resident questionnaires received confirmed that they had been issued with a contract by the home. From evidence seen during the inspection these responses must have been made by permanent residents as it was identified that residents accessing short-term care had not been issued with a contract (terms and conditions)to inform them of their rights. Contract (Terms and conditions ) documents seen were not current in respect of fee rates as the ones detailed were those relating to the previous financial year. It was disappointing that there was no evidence available to demonstrate that an assessment of need is carried out for each prospective resident particularly those entering the home for short-term care. Similarly, there was no evidence available to show that these residents’ had been given written confirmation that the home can meet their needs. John Dando Residential Centre DS0000034187.V308548.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The overall outcome for this group of standards is judged to be adequate. Care planning processes require further development and improvement to ensure that a care plan is produced for each resident at the time of their admission, that care plans are reviewed when changes occur and that residents’ are involved in the production of their care plan. Further improvement is needed to ensure that the total health care needs of each resident are met. Medication systems need further development and improvement to ensure that processes are robust and safe. Residents’ feel that they are treated with respect. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 12 EVIDENCE: A care plan was available for each resident with the exception of a new resident who had been admitted for short-term care. It was concerning that there was no care plan/ written instructions for staff to follow for this resident as they had a significant medical condition. A serious concern letter was issued by the Commission for this to be addressed. Care plan content needs fine tuning to ensure that all needs are included. There was no evidence that residents’ are being involved in the production of their care plan missing the opportunity for them to give their views and opinions. Care plan reviews need more attention to ensure that they are carried out when changes occur. It was identified that one resident had deteriorated significantly in terms of health, mobility and risk yet her care plan had not been up dated to reflect these changes. Six of the eight completed resident questionnaires received confirmed that they ‘ receive the care and support they need ‘ always. One usually and one sometimes. Generally residents’ seen were appropriately dressed with clean nails and hair. Records to evidence this however, as with past inspections are not being completed as they should be all the time. Whilst risk assessments and weight monitoring recordings were in place for some residents’ there were not any for new residents’ admitted for respite care. There was no evidence to demonstrate that these residents had been weighed on admission to gain a baseline weight. Further, staff could not confirm that residents accessing short-term care are weighed on discharge from the home. Records of visiting health care professional visits examples being; the dentist and chiropodist are not being completed with consistency as they should to evidence that residents’ are receiving these services. Tissue viability assessment scoring is not being carried out. The manager explained that she had spoken to the district nurse team who felt that this was a nursing task. The inspector informed that tissue viability assessments are carried out in care homes as a preventative measure on admission and where the score is high on a regular basis and that this is what is required. Is it positive that a proportion of staff have received dementia training to give them skills and knowledge to deal with residents’ in their care who have dementia. However, not all night staff or bank staff to date have received this training. It is positive that overall seven of the eight completed resident questionnaires received confirmed that they always receive the medical support they need, one answered usually to this question. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 13 Medication systems have improved somewhat over the last year however, further improvement is needed. An example being; all staff with a responsibility for medications should receive accredited medication training. Other shortfalls were identified in respect of medication safety examples being medication records not always being signed for after administration. Topical medications not being signed for. Where medication records are handwritten there was no evidence to suggest that two staff had checked that the information transferred from the medication box/packet was correct. It is positive that some requirements from previous inspections have now been met in that there are better instruction available for administration on records and an up to date pharmaceutical guide has been purchased. It is also positive that the home has taken the initiative to purchase an approved controlled drug register. Residents spoken to confirmed that they are treated politely by staff. One resident said; “ The staff are polite”. Another resident said;” The staff are very polite”. Interactions observed between staff and residents’ was positive. Staff giving choices wherever possible. All bedrooms are single occupancy to enhance privacy and dignity. The preferred form of address for each resident is determined on admission and used thereafter. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15. The overall outcome for this group of standards is judged to be good. Generally residents’ are satisfied with the daily routines. Activity provision needs to be greatly improved to ensure that there is sufficient stimulation and recreation provided. The home actively encourages residents’ to maintain contact with family and friends. Residents are encouraged where possible to take control of their lives. Residents’ receive a balanced diet in pleasing surroundings. EVIDENCE: Residents ‘ spoken to were happy with their daily routine. One resident said;” I don’t get up too early”. Another said; “ I have choices in what I do”. Activity provision is lacking which is concerning as the home is registered to provide care to a number of residents’ who have dementia and other conditions. To overcome this shortfall a dedicated activities provider should be employed to solely concentrate on activity provision. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 15 The home actively encourages residents’ to maintain contact with family and friends. Visiting times are open and flexible. There are a number of small lounges available for residents to receive their visitors in private. One resident said; “ I have visitors- friends and neighbours”. Another said; “ My family visit regularly”. One female resident confirmed; “ My son and grandchildren visit all the time”. Residents can bring into the home personal possessions to keep in their bedrooms. Advocacy information is detailed in the homes statement of purpose/ service user guide. The home is fortunate as a dietician is employed by the organisation to assist in menu planning and give advice. The home has attained a number of healthy eating awards. Each unit has its own dining area. The main meal of the day was observed on one unit. A staff member was on hand to give assistance. The meal was served by a member of the kitchen staff. The main meal for the day was spaghetti bolognaise or gammon with vegetables followed by shortcake and custard. The meals were attractively served and smelt appetising. One resident said; “ That was lovely” after she had finished her meal. Another resident said; “ The food is very good”. Feedback from resident questionnaires was surprising in that six of the eight confirmed that they usually like the meals, one sometimes and one always. Meal provision therefore, may need some further exploration with the residents. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 16 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): 16,18 The overall outcome for this group of standards is judged to be adequate. Further developments are needed to ensure that residents’ are fully informed of complaints procedures and abuse is prevented. EVIDENCE: No complaints have been received by the Commission about John Dando. One complaint/concern was made by a resident to the home in July 2006 which was managed satisfactorily and has been resolved. One resident said; “ I have no complaints at all”. Another said; “I have no concerns or complaints”. Sandwell Council has a corporate complaints procedures with leaflets and other materials available to advertise these. To date complaints procedures however, have not been produced in ‘user friendly’ versions to aid the understanding of residents who may have dementia or other conditions which could make reading printed words difficult. Four of the eight completed resident questionnaires received confirmed that they always know how to speak to if they are not happy, four answered usually to this question. Five of the eight confirmed that they usually know how to make a complaint, three answered always to this question. The home during the last twelve months has received a considerable number of thank you letters and cards in addition to formal compliments which is really positive. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 17 At least two incidents have occurred where there has been some violence between two residents. One of these incidents was reported correctly as per Sandwell Council’s vulnerable adults processes. It was noted in one residents’ records however, that another incident occurred yet there was no evidence of any follow up to this as there should be. This was pointed out to the acting manager during the inspection to deal with. Vulnerable adult policies and procedures an example being; the physical intervention policy has not yet been finalised and put into operation. It is positive that the majority of staff have received abuse awareness training which is provided by Sandwell council. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 18 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. The overall outcome for this group of standards is judged to be adequate. Residents live in a home that is maintained to a satisfactory standard. Further improvement is needed to ensure that the home is safe and hygienic. EVIDENCE: The home is a large detached building separated internally into four units. The ground floor smaller units cater for residents’ who have dementia. These units have signs and symbols to aid understanding and orientation. Redecoration work has been undertaken since the last inspection in a number of bedrooms and living areas. This looks fresh and clean. The manager in general is well aware of the redecoration needs outstanding in the home and is working to address this. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 19 Since the last inspection work has been completed to fit the required two double electrical sockets in each bedroom. A ground floor room has been adapted to allow easier free access to the garden for all residents’. The home has a garden to the front and rear. The rear garden is completely enclosed and is accessible and safe for all residents’ to use. The garden has been designed to enhance safety and orientation by using pathways and familiar features that lead back to the door. The garden is of a good standard and is valuable to the residents living at the home. As with the last inspection it was noted that water pipes in ground floor toilets are not all guarded posing as a potential risk to residents. Again water provided from hot taps during the afternoon felt cold. This must be addressed as it poses a risk of cross infection. Infection control processes need further development and improvement for example cleaning schedules are not being fully adhered to and there are no ‘hand wash’ signs provided in toilets and bathrooms. It is positive however, that the home has a mechanical sluicing disinfector And disposable gloves and aprons were readily available. A slight odour was detected in the ground floor hallway between the office and laundry. No more odours were detected in other areas. It is extremely positive that eight of the eight completed resident questionnaires received all confirmed that the home is always fresh and clean. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30 The overall outcome for this group of standards is judged to be adequate. On-going monitoring is needed to ensure that staffing numbers are adequate at all times particularly weekends. Service users are in safe hands at all times. Further developments are needed to ensure that recruitment practices promote service user safety. Generally staff are trained and competent to do their jobs. EVIDENCE: Five of the eight resident questionnaires received stated that staff were available when needed, one usually and one sometimes. One resident spoken to during the inspection said;” Definitely enough staff”. Staff views on staffing levels varied however, a trend emerged in that if at anytime there was ever staffing difficulties it was weekends. Obviously this situation requires thorough monitoring. It is extremely positive that eight of the eight completed resident questionnaires received all confirmed that staff listen and act upon what they say always. Positive comments were received about the staff as follows; “ The staff are very good, very polite”. “ Staff are very nice”. “ The staff are very good, very polite. Good carers”. The home has an N.V.Q attainment level of 56 of the care staff already having this award, which is very positive. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 21 It was disappointing that there was no staff file on site for a new casual staff member. The manager did however, manage to obtain some of the required documents before the inspection concluded. Staff files did reveal some shortfalls as there was insufficient sources of identity and evidence of POVA checks for some. A memo from the human resources department did confirm a clear CRB but did not mention a POVA list check. Further, there was no evidence of interviewing processes available. Evidence was available to demonstrate in-house and corporate induction processes. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36,38 The overall outcome for this group of standards is judged to be adequate. Service users live in a home which is well managed. Fine tuning is needed to ensure that the home is run in the best interests of the residents. Service users financial interests are safeguarded. Improvement is needed to ensure that all staff receive regular one to one supervision. Generally the homes compliance with health and safety is satisfactory. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 23 EVIDENCE: The organisation has made the decision for the acting manager to become permanent. She has applied to the Commission for registration and is awaiting a date for her fit persons interview. The home has robust quality assurance processes in place and is due to be reassessed for external accreditation in September 2006. Fine tuning in a number of areas is needed examples being; full feedback mechanisms for relatives, residents and other stakeholders- the results of which to be published. That all staff are aware of all operational policies and procedures and that monitoring of all National Minimum standards for older people is undertaken at least annually. Good processes are in place to protect residents’ financial interests. Seniors were observed checking resident money held in safe keeping between shifts. Records are made of deposits and transactions. Receipts are retained for expenditure including services provided by the hairdresser and chiropodist. Although there was evidence of staff formal; supervision. These are not being carried out to the required frequency and need improvement. Maintenance and equipment service records were assessed and were found to be satisfactory. Accident records are being completed but monthly analysis of accidents as a preventative measure is not being undertaken consistently. It was difficult to determine fully staff training uptake/ compliance. Generally, it appeared from records to have been attended or booked. One shortfall identified was the insufficient fire drill sessions provided. The kitchen was not assessed as it was inspected by environmental health in the last two months who were pleased with their findings. West Midlands Fire Service have also inspected the home and were pleased with their findings too. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 24 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 2 1 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 25 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 correct fee for any given financial year. The registered provider and manager must ensure that all residents’ accessing respite services are issued with a terms and conditions document. Timescale for action 01/10/06 2. OP2 5(1)(b) 01/10/06 3. OP3 14(1)(a) (b)(c) The registered provider and 22/09/06 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. The outcome of this assessment must detail a list of needs including the primary need examples being dementia, old age etc. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 26 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, 05/08/05 and 01/04/06 not met. There was no evidence again of assessment of need processes in respect of two residents who have been admitted for respite care. An immediate requirement followed by a serious concern letter was issued for this shortfall to be addressed. 4 OP4 14(1)(d) The registered provider and manager must ensure that all residents including those accommodated for respite are given written confirmation that their needs can be met as per Regulation 14(1)(d). 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. Timescale of 27/03/06 not fully met. DS0000034187.V308548.R01.S.doc 30/09/06 5 OP7 15(1) 30/08/06 John Dando Residential Centre Version 5.2 Page 27 6 OP7 15(1) The registered provider and manager must ensure that a full care plan for (KS) be produced detailing requirements concerning his condition. An immediate requirement followed by a serious concern letter was issued for this shortfall to be addressed. A copy of the care plan must be provided to the CSCI by 31 August 2006. 30/08/06 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 and 01/04/06 not fully met. 01/10/06 8 OP7 15(2)(2) OP8 9 12(1)(a) (b)17(2) The registered provider and manager must ensure that care plans are updated whenever there is a change to condition etc. ( No care plan update for (BH) deterioration and change in mobility ). The registered provider and manager must ensure that the care (tick) charts are maintained at all times. Timescale of 20/11/05 and 01/04/06 not fully met. 30/09/06 30/09/06 10 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. This also applies to night and casual staff. DS0000034187.V308548.R01.S.doc 01/11/06 John Dando Residential Centre Version 5.2 Page 28 11 OP8 12(1(a(b) 13(4)(c) 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 and 01/04/06 not met. 01/11/06 12 OP8 12(1(a(b) 13(1)(b) 13 OP8 13(4)(c) 14 OP8 13(4)(c) The registered provider and manager must maintain records of all health care visits, assessments and treatments for example those provided by the chiropodist, optician, dentist etc. The registered provider and manager must ensure that risk assessments are undertaken for all residents on admission this includes those who are admitted for respite care. The registered provider and manager must ensure that all residents are weighed on admission ( this includes those admitted for respite care who should also be weighed before discharge as well). The registered provider and manager must ensure that medication is signed for at the point of administration. Timescale of 04/07/05 and 25/03/06 not fully met 30/09/06 30/09/06 30/09/06 15 OP9 13(2) 25/09/06 16 OP9 13(2) The registered provider and manager must ensure that all prescribed topical preparations are signed for after application. Timescales of 20/07/05 and 25/03/06 not fully met. 30/09/06 John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 29 17 OP9 13(2) The registered provider and manager must ensure that all staff who have responsibility for medications receive adequate medication 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. Timescale of 25/03/06 not met. 01/11/06 18 OP9 13(2) 30/09/06 19 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. Timescale of 01/04/06 not Fully met. The later half of this requirement has not been met. 30/09/06 20 OP9 13(2) 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 not fully met. 30/09/06 John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 30 21 OP9 13(2) The registered manager must on a monthly basis audit medications being returned to the chemist to identify any high level of non-administration. Timescale of 27/03/06 not met. 30/09/06 22 OP9 13(2) The registered provider and manager must ensure that staff take extra care when dealing with medication such as Prednisolone to ensure that none are dropped etc and that tablets left tally with records. The registered provider and manager must ensure that written evidence is available at all times to show that prescribed dietary supplements such as Fortisips have been given. 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. This to give instructions to staff in what circumstances the medication should be given. The registered provider and manager must ensure that two staff verify and sign to witness any controlled drug being administered. The registered provider and manager must add to the homes’ medication policy instruction to staff on what they must do in case of a medication error. Reference should be included that any medication error must be reported to the CSCI in accordance with Regulation 37. DS0000034187.V308548.R01.S.doc 30/09/06 23 OP9 13(2) 30/09/06 24 OP9 13(2) 30/09/06 25 OP9 13(2) 20/09/06 26 OP9 13(2) 01/10/06 John Dando Residential Centre Version 5.2 Page 31 27 OP12 16(2)(n)1 8(1)(a) The registered provider and manager must employ a suitably qualified / dedicated activities person. Timescale of 01/06/06 not met. The registered provider and manager must ensure that activities are provided on a regular basis and that records are maintained of individual activity participation. Timescales of 20/07/05 and 01/04/06 not fully met. 01/11/06 28 OP12 16(2)(m) (n) 01/10/06 29 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. Timescales of 01/08/05 and 27/03/06 not fully met. 01/11/06 30 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, 01/08/05 and 01/04/06 not met. 01/11/06 31 OP18 13(6) The registered provider and 01/10/06 manager must ensure that all policies and procedures relating to adult protection are up to date and current. That staff read, sign and date these procedures. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 32 32 OP18 13(6) 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. 01/10/06 33 OP18 13(4)(c) 13(6) 34 OP24 16(2)(c) 23(2)(f) The registered provider and 20/09/06 manager must ensure that a record of all incidents of aggression is made and where needed these incidents are reported to the residents social worker or via Sandwell protection procedures. (For example the incident written on the daily notes of ES 11/08/06). 01/11/06 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 and 01/04/06 not fully met. Must be able to evidence consultation with each resident. Process must be repeated each new admission. 35 OP25 23(2)(j) 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. 30/09/06 John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 33 Timescale of 01/04/06 not fully met. Water in ground floor wash hand basins not even warm- infection control hazard. 36 OP25 13(4) The registered provider and manager must ensure that all exposed hot water pipes in bathrooms and toilets are suitably guarded. Some pipe work in toilets/ bathrooms still exposed. Was difficult to determine level of risk as at the time the water flowing through was not hot. 37 OP26 23(2)(d) The registered provider and manager must ensure that the cleaning schedule is consistently adhered to. Timescales of 20/07/05 and 01/04/06 not fully met. 38 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. Timescales of 20/07/05 and 27/03/06 not fully met. 39 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. Timescale of 27/03/06 not met. 01/10/06 01/10/06 01/10/06 01/10/06 John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 34 40 OP26 13(3) The registered provider and 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. Timescale of 01/04/06 not met. 01/10/06 41 OP26 13(3) 42 OP26 13(3) The registered provider and manager must identify, manage and eradicate the slight odour in the hallway located between the office and laundry area. The registered provider and manager must install a sink in the laundry for the sole purpose of staff hand washing. 30/09/06 01/11/06 43 OP27 18(1)(a) 44 OP29 13(6)19 (2) The registered persons must on 01/10/06 an on-going basis monitor staffing levels on weekends to ensure that they are adequate considering there is only one senior/manager on duty. Evidence must be available to demonstrate that senior/staff views are obtained and taken into account about the weekend staffing provision. The registered provider and 30/09/06 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. John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 35 Health declaration. Evidence that General Social Care Council codes of conduct and practice have been issued. Original enhanced CRB/POVA list check. Timescales of 04/08/05 and 01/04/06 not fully met. 45 OP33 24 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. Timescale of 01/05/06 not fully met. 46 OP36 18(2) The registered provider and 01/11/06 manager must ensure that all staff receive six supervision sessions in any 12-month period. A staff supervision matrix must be produced. Timescales of 01/08/05 and 01/04/06 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. 01/11/06 01/11/06 John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 36 Timescales of 28/08/05 and 01/04/06 not met. 48 OP37 17(2) The registered provider and manager must ensure that all staff read, date and sign the homes policies and procedures. Timescales of 10/12/04, 01/08/05 and 01/05/06 not fully met. 49 OP38 13(4(5)18 (1a)23(4) 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, 20/08/05 and 01/05/06 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. Timescales of 01/08/05 and 01/04/06 not fully met. 51 OP38 13(4)(c) The registered provider and manager must ensure that a monthly analysis of accidents/incidents is carried out with records made of findings. 01/10/06 01/11/06 01/11/06 01/11/06 John Dando Residential Centre DS0000034187.V308548.R01.S.doc Version 5.2 Page 37 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.V308548.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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