Inspection on 04/07/05 for John Dando Residential Centre

This inspection was carried out on 4th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 27/02/06

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 Cathy Moore Unannounced 4 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service John Dando Residential Centre Address Hamstead Road Great Barr Birmingham. B43 5EL 0121 357 7574 0121 351 9425 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sandwell MBC Mrs Beverley Hellend Care Home 39 Category(ies) of OP Old Age (19) Dementia over 65 years (20). registration, with number of places John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: PD(E) 1 Date of last inspection 09.11.04 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 who have a diagnosis of dementia, Ninteen to older people who do not have other needs. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 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 the 4 July 2005 between the hours of 08.10 and 18.15 hours. Two residents files were examined in detail which included the scrutiny of assessment documents, social work assessments, care plans, daily notes, weight monitoring records, health care visit documentation and medication administration records. Seven residents were spoken to, two in greater detail. Two residents bedrooms were assessed. Premises viewed during the inspection included the garden, a first floor lounge and the laundry. Three staff files were scrutinised. Three staff were spoken to as part of the inspection process. Health and safety and staff training records were also assessed. What the service does well: The home is a Local Authority owned and managed home which enables a support and advice network from management and specialists. The staff at the home appeared to be friendly, helpful, caring and kind. The manager and senior team keen to provide a high standard of care. The garden is of a generous size, safe, well maintained, accessible and suitable for the residents’ accommodated. The atmosphere of the home was warm, welcoming and friendly. Positive comments were received from residents’ examples of which are as follows; “I only came in last week, it has been lovely so far, my bedroom is o.k, the staff are fine and the food is lovely”. “ All staff are ever so nice”. “ I have been here for 14 years. The staff are very nice indeed. We are all good friends. There is nothing to be unhappy about here”. “ The staff are alright, I’ve got no cause for complaint at all. They do everything for me. If I need anything they help”. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 6 The home has recently received a number of compliments from relatives. Extracts from compliment letters include; “ Sincere thanks for the kindness shown to my mother”. “Sincere thanks to the staff for their care”. What has improved since the last inspection? 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 E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 8 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 standard(s) 2,3,5. Terms and conditions documents require updating and revision. The assessment of need process is inadequate and requires development. Prospective residents, their families and friends have the opportunity to visit and assess the home and to assess its quality and services. EVIDENCE: The two residents files assessed did include a terms and conditions document. The terms and conditions document detailed a previous financial years fee of £409.78 not this year’s fee of £447.22. The terms and conditions document did not specify who is liable if there is a breach or who is responsible for paying the fees. Assessment of need processes are not formalised. No specific assessment of need documentation is being utilised. One assessment of need process in respect of one resident had been recorded primarily on a ‘contact sheet’. A specific list of needs had not been produced as an outcome of the assessment process. The assessment record did not fully mirror needs included in the care management documentation. The homes document identified this resident’s needs as; “ Ring and ride for social gatherings”. “Allowed to get up and about.” “Partially sighted”. “ Activities”. The care management documents highlighted John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 9 some of this resident’s needs as “partially sighted”. “Anxiety attacks”. “Angina”. “Mobility critical as risk of wandering”. A letter confirming that prospective residents needs will be met was included on residents’ files. This did not however, detail the specific needs of each resident or describe how these will be met. One resident’s needs have become more complex. There was evidence that the staff had acted correctly in that they had referred this resident back to the social work team for reassessment. However, this referral had been made in 10/04, to date, no reassessment has been undertaken even though the home has requested this on a number of occasions. There was written evidence to demonstrate that residents are given the opportunity of an introductory visit to the home prior to their admission. This was confirmed by one resident who said; ” I came and looked around before I moved in”. The home has a trial period of 4 weeks in operation. This to give new residents the opportunity to determine the suitability of the home before their long term placement is made official. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 Care plans are poor. Development is needed to ensure that they are of a good quality and reflect the full needs of the residents’. The health care needs of the residents’ are not being fully met. Medication systems and procedures require further development to ensure the safety and well-being of the residents’. EVIDENCE: Two residents care plans were assessed in detail, two others viewed in less detail. Care plan content was seen to be poor. Needs not properly detailed or not mentioned. There was no instruction to staff on how they must meet needs identified. One resident has developed a decreased appetite and his food / fluid intake has decreased examples of this were written in his daily notes as follow; “ Refused meals at tea time”.“ Put him ready for his breakfast, did not eat much. Did not have his dinner as he was asleep”. There was no mention of this poor appetite and food intake in his care plan. Another resident has a pressure sore which is being dressed by the district nurses. There was no mention of this pressure sore in her care plan and no instructions to staff of how her skin should be treated or how she should be managed to prevent further tissue breakdown. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 11 One resident’s daily records indicate episodes of aggressive behaviour at times.“ appears to be very aggressive”. “ appears fine. Ate well, was very abusive and aggressive towards staff when being assisted to bed”. Another resident’s daily records indicate that he is confused at times. “ Remains very confused asking for bus fare to go home”. “ Has only slept for one hour throughout the night walking around shouting for (K) and Mum and Dad”. There was no mention in these residents’ care plans about their aggression or confusion. District nurses visited the home during the inspection to attend to two residents. A conversation was over heard whereby a senior was requesting regular district nurse input for a newly admitted resident who has diabetes. There was evidence of a recent visit from an optician and evidence to demonstrate that doctors are requested when needed. There was no evidence that tissue viability assessments or specific falls risk assessments are being carried out. Only a small proportion of residents had been weighed in June 2005. A number of nutritional assessments had not been carried out since June 2004. . One resident has lost 1 stone 6 lbs since 02/05, yet there was no evidence that he had been referred to his doctor about this or the dietician. There was no evidence to suggest that this resident’s diet and fluid intake was being monitored adequately. Two residents’ had not been seen by a chiropodist or dentist for some considerable time. Risk assessments in terms of behaviour, aggression and changes in physical health are not being carried out diligently or consistently. Records in respect of one resident stated: “Mobility is deteriorating. Staff finding it difficult to wash and dress her, risk to staff’s back”. “very abusive and aggressive towards staff”. There was no evidence that a recent risk assessment had been carried out and no evidence that any violence and aggression reports had been completed in respect of this resident’s aggression towards staff. Tick charts (form S5534/1) in respect of personal care delivery are not being completed diligently or consistently. One resident’s personal care tick chart had not been completed since the 18.5.05, another resident’s had not been completed since 26.6.05. ` One resident commented” They look after you well, they wash me on the bed. They wash my clothes even if they have only been worn for a couple of hours”. The latter however, was not said positively”. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 12 Medication was not assessed in full. Eleven staff signature gaps were observed on one resident’s medication administration record between the dates of 18.6.05 and 2.7.05. There was no pharmaceutical guide under twelve months old available. One resident had refused one medication for most of June 2005, this was prescribed to be given four times per day, not on a ‘when required basis’. Staff who administer medications were not aware of how one resident’s medication should be given. This particular medication (Alendronic Acid) has ‘ counselling’ instructions which must be observed; “ Tablets should be taken whole when sitting or standing. To be taken 30 minutes before breakfast (or other oral medication). Patient should stand or sit upright for at least 1 hour after taking tablets”. One resident had been prescribed 15 antibiotics on 10 June 2005 yet there were only 11 signatures to confirm administration. Records showed that this medication, which must be given as prescribed, had been omitted on a number of occasions, as the resident was asleep. An example staff signature list was available in respect of staff who administer medication. Medication records seen had attached a photo of the resident. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 12.14 Residents’ lifestyle experiences in the home do not always match their expectations and preferences. Residents; are in general helped to exercise choice and control over their lives. EVIDENCE: There was little evidence to demonstrate that the preferred name, daily routines and other preferences are determined and recorded for each resident. One resident commented, “At night they take me away from my programme at 7.30 P.M to change me. If you don’t want to go you shouldn’t have to, being told to go to bed early”. Activity provision has diminished, this in part due to the dedicated activities provider being off sick. There were few activity sessions recorded for the month of June 2005. Main activities recorded for May 2005 included a Victory in Europe celebration and an external entertainer. There was evidence of resident consultation in that meetings are held fairly regularly. A number of bedrooms were viewed during the inspection. These bedrooms held a range of residents’ personal belongings. One resident had his own fridge and radio in his bedroom, another a wall unit/ book case and an John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 14 electronic adjustable height bed. These items were not however, included on their inventories. External advocacy information was seen included in the home’s introductory materials. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 16,18 Policies and procedures in respect of complaints and the prevention of abuse are unsatisfactory and require review. EVIDENCE: Complaints procedures / information in the home did not mention the Commission for Social Care Inspection, thus did not give their address or telephone number. Complaints leaflets in the home were seen produced in standard font format only, not in formats appropriate to the needs of the residents who have poor eyesight and dementia. No recent complaints have been received by the home or the Commission for Social Care Inspection. The home has recently received a number of compliments from relatives. Extracts from compliment letters include; “ Sincere thanks for the kindness shown to my mother”. “Sincere thanks to the staff for their care”. It was pleasing to see evidence to demonstrate that the majority of staff have received recent adult abuse awareness training provided by Sandwell MBC and approved by Sandwell’s Adult Protection Co-ordinator. Adult protection policies and procedures must be up dated to reflect Sandwell Vulnerable Adult policies and procedures. Violence and aggression and restraint procedures are being reviewed. One incident of concern has been highlighted and reported and is being investigated at the present time. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19,24,26 Residents’ generally live in a safe, well maintained environment. Improvements are needed in some areas, for example, ongoing maintenance programmes. Further choice needs to be given to residents’ in respect of their private accommodation. Laundry processes require attention to ensure this area is clean and hygienic. EVIDENCE: There was no evidence available to demonstrate that a recent audit had been undertaken in respect of the redecoration and replacement needs of the home. A number of bedrooms seen will require redecoration in the near future. A number of chairs seen in the big, first floor lounge were faded, one had fabric which had split on the seat. The home has a large, attractive, well maintained rear garden that is enclosed and safe. The garden is well used in the spring and summer months a new door has been fitted complete with ramp and handrails to enable all residents safe access to the garden. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 17 Two bedrooms were fully assessed during the inspection. One room, 18 was of a good size to house hoisting equipment. The bedding and mattress in this room were satisfactory. The décor and carpet reasonable but will need to be included in the maintenance programme. There was only one double electrical socket in the bedroom, although there was a number of electrical items including the bed and a hoist. Bedroom 9 was seen to be comfortable. The décor will need attention in the near future, the carpet stained under the wash hand basin. This room had two double and one single electrical socket. There was no evidence to suggest that an audit of the bedrooms has been carried out against standard 24.2. There was evidence that the occupants of both of these rooms had been offered a key to their bedroom door. Both had a lockable facility available although, due to their height they may be difficult to access. One resident said of their bedroom, “ my bedroom is o.k, I like it”. Another resident commented “ ever so nice bedroom”. Another said, “ my room is alright, you can not expect a palace”. Two bedrooms viewed had an odour. The home has recently purchased and has had fitted a mechanical sluicing disinfector. The home employs dedicated laundry staff. The home has 3 washing machines all with a sluice cycle. The walls in the laundry appeared satisfactory. The flooring looked relatively new, intact and of a good standard. The home has a laundry cleaning schedule however, records of cleaning shelving and other areas had not been completed since April 2005. The mop had been left in water. A lock is available on the laundry door to prevent unauthorised access. No other areas of infection control were assessed. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 Service user needs are not always met due to the high usage of agency staff. Recruitment processes are insufficiently developed. EVIDENCE: Recent interviews have taken place and new staff have been appointed subject to the required checks. Staffing at the present time was found to be unsatisfactory at times, for example the evening of the 3 July 2005 when only agency care staff were on site, no permanent staff members apart from the senior. Past accident analyse show that a significant number of falls or near misses have occurred at night. Staff recruitment processes are inadequate in terms of records held in the care home. Files viewed did not all include a photograph, interview questions and answers, two written references, original enhanced disclosure/ POVA list check, evidence that General Social Care Council codes of conduct and practice had been issued or health declaration. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36,37,38 Staff supervision in terms of frequency is not adequate. Residents’ rights and best interests are not being safe guarded by the homes record keeping, policies and procedures. Greater observance and diligence is required in respect of staff mandatory training and health and some areas of health and safety. EVIDENCE: Not all staff have received the required six supervisions or supervisions plus appraisal in the last 12 months. Records seen such as care plans were poor. Daily notes entries were not always concise or followed through. One entry in the daily notes stated 21.5.05 “ threw up this A.M”. It was identified that there was no label to evidence that the radio in (HG) John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 20 room or the television in (VS) room had been PAT tested. Not all staff have attended the required 2 fire drills in any 12 month period. The fire risk assessment was last reviewed in 2001. A letter dated 19/1/05 was on file corresponding to the list of requirements in terms of work needed following the last 5 year fixed electrical wiring test. There was no evidence to suggest if this work has been carried out or completed. The last service certificates for the hoisting equipment were dated 11/04. It was identified that a number of catering staff food hygiene certificates may have lapsed. There are a number of gaps in the staff training records in respect of mandatory training. COSHH data in the laundry did not reflect all substances stored. Substances such as’ toilet duck’ and ‘ All fresh’ liquid odour prevention were stored in the laundry yet there was no manufacturers data for these available. The kitchen was not assessed. John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 x COMPLAINTS AND PROTECTION 2 x x x x 2 x 2 STAFFING Standard No Score 27 1 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x 2 2 1 John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5(1)(b) Requirement The registered provider and manager must ensure that residents terms and condition documents detail the following: The correct fee for any given financial year. Who is responsible for paying the fee. 2. OP3 14(1)(a)( b). 14(1)(c ) Who is liable if there is a breach. The registered provider and 04.08.05 manager must ensure that a thorough and robust assessment of need process is developed and implemented with accompaning documentation. This process must include all main areas of care, standard 3.3 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. Evidence must be available to demonstrate that the prospective John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 23 Timescale for action 04.08.05 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 user. 3. OP3 OP4 14(1)(d) Timescale of 9.11.04 not met. The registered provider and manager must, where social workers do not act in a timely fashion in response to reassessment of need requests ,refer these incidents to their senior managers for resolution. The registered provider and manager must ensure that the Regulation 14 (d) letter is expanded upon. The list of needs identified ( as described in requirement number 2 ) must be detailed within the individual residents letter with confirmation of how these will be met. The registered provider and manager must ensure that a care plan is produced in respect of ( H.G) poor appetite, poor fluid intake and confused state.These care plans must be precise. An Immediate requirement was issued during the inspection. A serious concern letter was sent by the CSCI following this inspection in which this requirement was included. 04.07.05 4. OP3 OP4 14(1)(d) 04.07.05 5. OP7 12(1)(a) 12(1)(b) 15(1) 15(2)(b) 04.07.05 John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 24 6. OP7 12(1)(a) 12(1)(b) 15(1) 15(2)(b) The registered provider and manager must ensure that (H.G) care plan states what the problem is, what must be done, when, how, how often and by who. A serious concern letter was sent by the CSCI following this inspection in which this requirement was included . The registered provider must ensure that care plans cover all initial needs assessed , diagnosis, the full specrtum of activities of daily living, medications , individual goals , aspirations, preferences and choices. Timescale of 10.12.04 not met. The registered provider and manager must ensure that all residents care plans reflect their full needs, any identified concerns or risks. A serious concern letter was sent by the CSCI in which this requirement was included. Care plans must cover aggression, confusion, diet and fluids, personal care delivery, pressure area/ sore care/ tissue breakdown prevention, risks, concerns,diabetic care, incontinence, continence promotion, activities etc. The registered provider and manager must ensure that all residents care plans are precise in instruction and content as follows: What is the problem/need. 04.07.07 7. OP7 12(1)(a) 12(1)(b) 15(1) 15(2)(b) 06.07.07 8. OP7 15(1) 15(2)(b) 06.07.05 9. OP7 15(1) 15(2)(b) 06.07.05 John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 25 What must be done, how, how often and by who. A serious concern letter was sent by the CSCI in which this requirement was included. The registered provider and manager must ensure that residents care plans are accuratley reviewed on a regular basis or immediatley if a new concern, risk or anything else significant occurs. 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. The registered provider and manager must ensure that the care ( tick) charts are maintained at all times. Timescale of 20.11.04 not met. 13. OP8 12(1)(a) 12(1)(b) 17(1)(a)SCHED 3 (m) The registered provider and manager must monitor consistently and diligently all ( H.Gs) food and fluid intake using appropriate methods of recording. A serious concern letter was sent by the CSCI in which this requirement was included. The registered provider and manager must refer (H.G) to his doctor and to the dietician . A serious concern letter was sent by the CSCI in which this requirement was included. The regsietered provider and manager must undertake written risk assessments ( concerning issues highlighted in respect of Immediate 04.07.05 10. OP7 15(1) 15(2)(b) 13(4) 12.07.05 11. OP7 15(1) 12.07.05 12. OP8 12(1)(a) 12(1)(b) 17(2) 04.07.05 14. OP8 12(1)(a) 12(1)(b) Immediate 04.07.05 15. OP8 12(1)(a) 12(1)(b) 13(4)(c ) 06.0.7.05 John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 26 (H.G) and include the findings from these in the care plan. A serious concern letter was sent by the CSCI in which this requirement was included. The registered provider and manager must ensure that additional documentation is in place to evidence how care or other areas have been delivered or is being monitored/ managed depending on the need for example food/ fluid input records, turn/ change of position records, behaviour monitoring records or any others deemed to be appropriate. A serious concern letter was sent by the CSCI in which this requirement was included. The registered provider and manager must ensure: That all aggressive behaviours towards staff are reported to the appropriate persons as per Sandwells violence and aggression monitoring processes/ documentation. That all risks identified concerning staff ( for example the entry concerning resident V) are dealt with effectivley and in a timely fashion. Written instructions must be available to staff to prevent/ minimise further risks. 20.07.05 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. Version 1.40 Page 27 16. OP8 OP37 12(1)(a) 12(1)(b) 17(2)(a)SCHED 3(m) 06.07.05 17. OP8 OP18 OP37 17(2) 04.07.05 18. OP8 12(1)(a) 12(1)(b) 13(4)( c) John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc 19. OP8 12(1)(a) 12(1)(b) 13(4)( c) 20. OP8 12(1)(a) 12(1)(b) 13(4)(C ) The registered provider and manager must ensure that regular nutritional assessments are carried out in respect of each resident. The outcomes of these nutritional assessments must be recorded. The registered provider and manager must ensure that all residents are weighed on admission and monthly thereafter. If weight loss is identified then the resident must be referred to their doctor and / or the dietician. The registered provider and manager must ensure that specific falls risk assessment processes is developed and implemented. Falls risk assessments must be carried out with records made on each resident admitted to the home and regularly thereafter. The registered provider and manager must ensure that moving and handling assessments are carried out and recorded in respect of each resident admitted to the home. Moving and handling assessments thereafter must be carried out regularly or to review dates set ( see V records- should have been reassessed in 05/05). The registered provider and manager must ensure that all residents have access to all main health care services either on a regular or as needed basis. This to include chiropidist, dentist, optician, dietician etc). The registered provider and manager must ensure that medication is signed for at the 25.07.05 04.07.05 21. OP8 13(4)(c ) 25.07.05 22. OP8 13(4)( c) 04.07.05 23. OP8 12(1)(a) 12(1)(b) 13(1)(b) 04.07.05 24. OP9 13(2) 04.07.05 John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 28 point of administration. 25. OP9 13(2) The registered provider must ensure that where antibiotics or other medication is prescribed on a short term basis, the full course is taken. Where there are problems with administration or otherwise then the residents doctor must be informed. 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 expediant for the doctor to be informed sooner than this for medications such as steriods, heart regulators or anti- coagulants). 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. The registered provider must ensure that all staff who have responsibility for administrating medications are aware of all special instructions for these medications. The registered provider and manager must request that the homes pharmacy provider provides for each medication being held in the home a patient information leaflet which is included in all medication packaging. These can then be used for staff reference/ guidance purposes. The registered provider and manager must ensure that a care plan for each resident is produced in respect of their 04.07.05 26. OP9 13(2) 15.07.05 27. OP9 13(2) 20.07.05 28. OP9 13(2) 20.07.05 29. OP9 13(2) 04.08.05 30. OP9 13(2) 04.08.05 John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 29 31. OP9 13(2) 32. OP12 16(2)(m) (n) 33. OP12 16(2) 34. OP14 17(2) Schedule 4 (10) prescribed medications. This must include a full list of current medications and any specific instructions. This must be maintained and be accurate at all times. The registered provider and manager must ensure that all prescribed topical preperations are included on the residents medications records and are signed after application. The registered provider and manager must ensure that activities are provided on a regular basis and that records are maintained of individual activity participation. The registered provider and manager must ensure that individual activitiy/ stimulation needs are determined for each resident and included in their care plan. The registered provider and manager must ensure that all items of furniture brought into the home by residents are included in their presonal inventory. 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. Timescale of 5.1.05 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. 04.07.05 20.07.05 01.08.05 01.08.05 35. OP16 22(2) 01.08.05 36. OP16 22(7)(a) 20.08.05 John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 30 37. OP18 13(6) The registered provider and manager must ensure that homes Whistle Blowing policy or procedure for staff who witness bad practice be reviewed in accordance with Sandwell MBC Adult Protection Procedures and Department of health guidance No Secrets. Timescale of 3.1.05 not met. The registered provider and manager must ensure that all staff read, sign and date the Procedure for staff who witness bad practice/ Whistle blowing policy. The registered provider and manager must ensure that all policies and procedures aimed to protect vulnerable adults including reporting procedures and Sandwell MBC leaflet Adult Abuse, What People Working in Sandwell Need to Know are all revised to accord with Sandwell MBC Multi-agency Adult Protection Policies and Procedures. The registered provider and manager must adapt 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. Timescale of 10.12.04 not met. The registered provide and manager must ensure that a written audit of all replacement and redecorating is underatken on a regular basis. Timescales must be attached where work has been identified as being needed. The registered provider and manager must ensure that the 20.08.05 38. OP18 13(6) 01.09.05 39. OP18 13(6) 01.09.05 40. OP18 13(6) 01.09.05 41. OP19 23(2)(b) 23(2)(d) 01.08.05 42. OP19 23(2)(b) 01.09.05 Page 31 John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 43. OP24 23(2)(f) damaged chairs in the big first floor lounge are replaced. The registered provider and manager must ensure that all of the service users bedrooms are equipped with two double electrical Sockets. Timescale of 10.12.04 not met. The registered provider and manager 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. 01.09.05 44. OP24 16(2)( c) 23(2)(f) 01.09.05 45. OP26 16(2)(k) 46. OP26 23(2)(d) 47. OP26 13(3) The registered provider must 01.08.05 identify, manage and erradicate any odours in individual bedrooms. The registered provider and 20.07.05 manager must ensure that the laundry cleaning schedule is consistently adhered to. The registered provider must 20.07.05 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. The registered provider and manager must ensure that a stock of aprons and gloves are available in the laundry at all times. The registered provider and manager must ensure that ongoing recruitment for permanent staff continues to prevent the usage of agency staff. A serious concern letter was sent by the CSCI in which this 48. OP26 13(3) 20.07.05 49. OP27 18(1)(a) 18(1)(b) 05.07.05 John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 32 requirement was included. 50. OP27 18(1)(a) The registered provider and 05.07.05 manager must ensure that untill the full complement of staff is reached that at least one staff on each floor is a staff member permanently employed by John Dando. A serious concern letter was sent by the CSCI in which this requirement was included. The registered provider and 05.07.05 manager must carefully monitor the night staff regarding the On-going decrease in staffing numbers. If it is felt that the needs of the residents are not being met or there is an increase in accidents/ near misses or complaints then the night staffing levels must be increased immediatley. 04.08.05 The registered provider and 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. Timescale of 10.12.04 not met. This to include the following; Application form Interview questions and answers. Two written references on from the last employer. Health declaration. Evidence of Job description and contract. Evidence that General Social Care Council codes of conduct John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 33 51. OP27 18(1)(a) 52. OP29 13(6) 19(2) and practice have been issued. Original enhanced CRB/POVA list check. The registered provider and manager must ensure that all staff recieve six supervision sessions in any 12 month period. A staff supervision matrix must be produced. The registered provider and manager must ensure that all staff receive Care planning and record keeping training. The registered provider and manager must ensure that all staff read, date and sign the homes policies and procedures. Timescale of 10.12.04 not fully met. The registered provider and manager must ensure that a system is implemented where designated seniors or managers regularly select a number of residents files - care plans and records to ensure that all that should be in operation are in operation , that they are of a good standard and are being maintained dilgently and consistently . A serious concern letter was sent by the CSCI which included this requirement. The registered provider and manager must ensure that no staff prepare, cook or serve food unless they have received food hygiene training within the last three years. An immediate requirement to this effect was issued during the inspection followed by a serious John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 34 53. OP36 18(2) 01.08.05 54. OP37 17(2) 18(1)(a) 17(2) 20.08.05 55. OP37 01.08.05 56. OP37 17(2) Schedule 3(m) 20.07.05 57. OP38 18(1)(a) 18(1)( c)(i) 04.07.05 58. OP38 13(4) 13(5) 23(4) concern letter which included this requirement. The registered provider and manager must ensure that all staff receive training in first aid, moving and handling( including hoist training) health and safety, fire training and food hygiene. Timescale of 10.12.04 not fully met. 20.08.05 59. OP38 23(4) 60. OP38 13(4) The registered provider and manager must ensure that all staff receive fire drill instruction twice in any 12 month period. The registered provider and manager must ensure that all work identified on the latest 5 year fixed electrical wiring certificate has been addressed. Evidence that this work has been completed must be forwarded to the CSCI office. The registered provider and manager must review the homes fire risk assessment. The registered provider and manager must ensure that an accident analysis is carried out each month. The registered provider and manager must ensure that all hoisting equipment is serviced. Copies of the service certificates must be forwarded to the CSCI. The registered provider and manager must forward evidence to the CSCI to demonstrate that the radio in (HG) and television in (VS) room have been PAT tested in the last 12 months. 01.08.05 04.08.05 61. 62. OP38 OP38 23(4) 13(4) 01.08.05 01.08.05 63. OP38 13(4) 01.08.05 64. OP38 23(4) 01.08.05 John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 35 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations John Dando Residential Centre E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 36 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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 E55 S34187 John Dando V236297 040705 Stage 4.doc Version 1.40 Page 37 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!