CARE HOME ADULTS 18-65
Kathleen House 59-61 Addison Road Brierley Hill Dudley West Midlands DY5 3RR Lead Inspector
Mrs Jean Edwards Unannounced Inspection 10th November 2005 08:40 Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 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 Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 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 Adults 18-65. 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. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Kathleen House Address 59-61 Addison Road Brierley Hill Dudley West Midlands DY5 3RR 01384 70187 01384 70187 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) Mr R Murray Mr P Murray Ms Hilary Jordan Care Home 15 Category(ies) of Learning disability (15), Physical disability (15) registration, with number of places Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 15 PD and up to 15 LD, not exceeding the total number registered for. No service users who are wheelchair users be accommodated at 59a Addison Road. 21/07/05 Date of last inspection Brief Description of the Service: Kathleen House is a purpose built Home, opened in 1995. It provides residential care on a short-term respite basis for up to fifteen younger adults with learning/physical disabilities, at any one time. The Home comprises three self-contained bungalows, each accommodating up to five people. Located in a residential area, it blends in well and has easy access to local amenities and public transport with links to towns such as Brierley Hill, Dudley and the Merry Hill shopping centre. Externally the property is well maintained, with car parking at the frontage and space between the bungalows. To the sides and rear of the premises are well-maintained gardens, with small patios, lawned areas, mature trees and shrubs. The interiors of the bungalows are domestic in style, promoting a homely environment and maintained to high standards. Beds at the Home are block purchased by Dudley Social Services Department. In excess of one hundred and forty guests use the service. There is a stable staff team, with leadership provided by the Registered Manager, who has been in post since the Home opened. The service has been extended with an additional bungalow, which was registered on 13th February 2004, to provide up to 15 places. Additional staff were recruited, inducted and trained prior to the new registration. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection has taken place between 8:40 a.m. and 3:40 p.m. The purpose of this inspection visit is to assess progress towards meeting the national minimum standards and the homes progress to improve areas identified at previous inspection visits. A range of inspection methods has been used to make judgements and obtain evidence, which include: discussions with the Registered Manager, the trainee manager, guests and other staff. A number of records and documents have been examined, including responses to recent complaints. Other information was gathered prior to the inspection visit, from reports of visits undertaken by the owner’s representative and an action plan submitted by the home following the last inspection. Ten guests are in residence at the time of this visit and six people have chosen to stay at Kathleen House during the day of the visit instead of attending other day opportunities. Two guests in particular have been eager to be involved in the inspection process and all guests have been involved in discussions in varying degrees. The registered manager is now undertaking wider responsibilities within the organisation and the trainee manager, who has worked at the home for many years as a senior worker, is taking an increased level of responsibility for Kathleen House. What the service does well:
The registered manager responded to the previous inspection report with a comprehensive action plan, giving dates for the required improvements to be put into place. The majority of required improvements from the last inspection visit have now been put in place. Information about the home and the service it provides is readily available on the premises. People are able to visit the home prior to staying and can have as many short visits for meals or overnight stays as they feel they need before deciding to stay for longer visits. The Manager and staff provide advice and support to all families using the service provided by this home. Although the guests only visit for short periods of time, they are encouraged by staff to treat Kathleen House as their own home and to be as independent as they wish. Guests are able to make their own choices and take an active part in the running of the home, with an annual survey conducted so that everyone has an opportunity to freely air views about the running of the home. The outcome of the surveys can be seen on the notice boards.
Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 6 The manager and staff make sure that each guest and as appropriate their relatives are involved in the plan of how their care is to be provided, each person has a written personal profile. The home also has good relationships with local GPs and other community and health care services, which provide support for guests using the service provided by Kathleen House. All guests are able to spend their leisure time either in the home with a range of stimulating activities supported by staff or pursuing their individual interests in the wider community, decisions which are fully supported. Kathleen House is tidy, homely and comfortable. There are attractive arrangements of fresh flowers in the main lounge in 61, Addison Road. The home does not employ domestic staff and everyone is involved in cleaning duties. The bungalows and grounds are maintained to high standards. There is ample evidence of the volunteer gardeners skills and attention; the grounds and gardens look very well maintained. Kathleen House continues to have a stable staff team; some people have worked at the home for a long time and know the majority of guests well. They are caring, committed and flexible, often willing to work extra shifts, especially to support guests with outings and trips. Members of staff continue to demonstrate a dedicated approach to their work; they clearly know guests’ likes and dislikes and how to meet their needs. They readily answer questions in an open and honest manner. This inspection was conducted with full co-operation of the registered manager, trainee manager, staff and guests. The atmosphere through out the inspection has been relaxed and friendly. The Inspector would like to thank the manager, staff, and guests for their hospitality during this inspection visit. What has improved since the last inspection?
The home now makes sure that signature sheets are completed on admission with all guests and their family or representatives to show that they agree with information written about them in their personal profile. This may be about medicines they need or safety equipment such as bedrails on their beds to prevent them accidentally rolling out of bed. Action has been taken to replace the damaged work surface in the kitchen at 61, Addison Road, which improves food safety. There is a very attractive replacement three-piece suite in the lounge at 61 Addison Road. The trainee manager has introduced a system where members of staff move to work in a different bungalow every six weeks so that they all get to know all of
Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 7 the guests over a period of time. This is important because the home offers a respite service to more than 140 people from the Dudley borough. There is also a weekly auditing process in place, with an award and shared box of chocolates for the team and bungalow achieving the best performance over a number of areas. The manager has increased the information needed for staff personnel files. These now contain a recent photograph, and information about the job role and tasks each person is expected to do as well as their contract and terms & conditions of employment. These improvements provide additional safeguards for guests using the services provided by the home. The home has made a number of improvements to comply more fully with health and safety legislation. For example risk assessments relating to the environment and guests activities have been reviewed and expanded, with detailed controls measures to minimise any hazards. What they could do better:
The home has had six complaints since the inspection visit in July 2005. The management have investigated all complaints, five were upheld and one was not upheld. The trainee manager has taken appropriate action to resolve the issues raised and discipline members of staff as needed. The home must take additional measures to reinforce appropriate good working practice, such as obtaining staff signatures to demonstrate their awareness of the homes confidentiality policy and introduce monitoring arrangements to make sure all guests dietary needs are appropriately catered for. During a tour of the bungalows it has been noted that a small number of minor improvements are needed, which include replacing the missing headboard in the blue room at 61 Addison Road, making sure bed guards are not left in place or alternatively turning beds around to wall, for guests not requiring them. Whilst the communal bathrooms in all three bungalows are attractive and well maintained the registered person must replace the perished and mould covered anti-slip bathmat at 61 Addison Road. The registered manager is currently involved in wider responsibilities within the organisation therefore the organisation must submit an application to the CSCI for the registration of the trainee manager within three months, to formalise the dedicated managerial support for Kathleen House. Records at this home are generally very good, however the registered person must make sure that the CSCI is kept informed about all matters relating to the guests well being and especially relating to staff misconduct and disciplinary sanctions. Minor improvements are required to comply with health and safety regulations, for example first aid boxes at 59a and 61 Addison Road need to be restocked
Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 8 and the manager must resume the recorded accident analysis on a regular basis. The Registered Proprietors must send their business and financial plan, and last set of audited accounts to the CSCI Satellite Office, Halesowen for consideration. This is an outstanding required action for a considerable time. 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. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards have been assessed at the inspection visit 21 July 2005 and found satisfactory EVIDENCE: Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,10 There is a clear and consistent care planning system, personal profile, in place to adequately provide staff with the information they need to satisfactorily meet guests needs. EVIDENCE: The home uses the term personal profile to refer to the care plan because of the short-term service provided by the home. From a sample of case files examined there is satisfactory evidence that each guest has a comprehensive personal profile in place; new updated versions are being used for new people using the service, with some older style formats still in use for long standing guests. The trainee manager has put systems in place to ensure that signature sheets are completed on admission with all guests / representatives to indicate their agreement with their personal profile, for example for medication and use of any measures such as bedrails. The home conducts a full assessment process involving guests, families and other agencies to ensure that information such as limitations on facilities,
Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 12 choice or rights is recorded on the Home’s assessment proforma and is transferred to the personal profile. The personal profiles contain a summary including a pen picture of the person. Preferred name, personal care, preferred daily routines; times of rising and retiring, sleeping patterns, such as number of pillows, lights and night checks are well documented. Details of likes, dislikes, favourite foods and preferred activities and friendships are recorded. Personal profiles give staff ample guidance about each persons preferences such as having two pillows and the light off at night, liking music tapes and the TV. There is evidence that the home participates in reviews held by other agencies such as day care services or the community healthcare professionals. It is agreed that a practical approach to reviews initiated by the home, is to hold an annual review for each guest as a minimum, as there are now in excess of 140 people using the service. More frequent reviews can be held as needed. One case file sampled had review notes of meeting held with Kathleen House in February 2004 and February 2005. There is a comprehensive risk assessment system in place for each person. These have been reviewed and expanded to include activities within the home environment and on outside activities, where the home has a duty of care. The home has comprehensive policies and procedures relating to protecting guests privacy and rights to confidentiality. However a recent compliant investigation identified staff misconduct, where confidentiality had not been maintained. The home acted appropriately issuing disciplinary sanctions. As an additional safeguard staff signatures need to be obtained to demonstrate awareness of the homes confidentiality policy. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14,16,17 Links with the community are good and there are planned and spontaneous activities available on a regular basis. Guests are able to take advantage of and develop socially stimulating opportunities. The meals are generally good with evidence that guests are offered choice and quality meals. There is now some improved evidence relating to how the special dietary and nutritional needs of some guests are being met. EVIDENCE: There is clear information recorded on guests personal profiles of their preferences relating to their leisure time activities. From discussions it is evident that staff devise activities and outings to suit the guests accommodated at any particular time. Guests spoken to indicated that they enjoy going to the local pub, cinema, shopping - particularly to the Merry Hill Centre; and watching TV, listening to DVDs and playing games with staff and other guests. The home uses activity sheets, which are given to the guest to take to their own home at the end of their visit. The home also uses communication sheets, seen on case files for messages between Kathleen House and the main carers, and other venues such as day care opportunities.
Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 14 During the visit staff have been warm and friendly as well as being respectful towards guests. Members of staff can be heard using each guests preferred name. These are recorded in the sample of personal profiles assessed. Staff know and understand when guests’ need to be alone on occasions and their right to choose to be involved, such as the two who have taken an active role in this inspection. A senior member of staff does the shopping on a weekly basis, with menus devised to meet the preferences and needs of guests accommodated. During a tour of the premises it was noted that there was a good variety of fresh, frozen, canned and dried foods. Menu choices are recorded retrospectively. A recent complaint made to the home concerned failures to provide an appropriate low fat, low cholesterol diet for a particular guests packed lunches. This persons parent raised the issue on more than one occasion that a healthy diet had not been provided, instead white bread had been used to make spam sandwiches and the had lunch included a chocolate biscuit. The trainee manager had investigated and upheld the complaint, and issued disciplinary sanctions are members of staff concerned. A food diary has also been introduced, which improves the systems of communication between the home and the main carer. In addition the home is advised to implement monitoring arrangements to ensure all guests dietary needs are appropriately catered for. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards have been assessed at the inspection visit on 21 July 2005 and found to be satisfactory. EVIDENCE: Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The home has a complaints system, produced in pictorial formats, with evidence that guests feel that their views are listened to and acted upon. Policies, procedures, guidance and staff training have been implemented in order to provide guests with more safeguards from abuse. EVIDENCE: The home has a comprehensive complaints policy and procedure, with helpful flow charts in an innovative pictorial format. These help guests to understand the process. People spoken to state that they can tell the manager or staff about any concerns or things they do not like. The Home has received 6 complaints since the inspection visit 21 July 2005, which have been appropriately investigated and resolved. Five complaints were upheld. The Home’s complaint log is satisfactory clearly identifying outcomes of investigations and actions. The issues raised in the most recent complaint relating to failure to provide a suitably healthy diet as a packed lunch for one person have been reassessed as part of this inspection visit. There is satisfactory evidence that the trainee manager has dealt appropriately with the situation and separate communication will be sent from the CSCI to the complainant. The home has comprehensive policies and procedures and staff training is continuing relating to the areas of the protection of vulnerable adults, understanding abuse, whistle-blowing, bullying, dealing with aggression from guests towards staff, use of physical intervention / restraint, and management of stress.
Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 17 The home has a finalised copy of the multi-agency policy and procedure for the protection of vulnerable adults Safeguard and Protect available for staff guidance. The trainee manager is in the process of making sure that all staff read and signed the document to demonstrate their awareness. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,29,30 The standard of the environment within this home is good providing guests with an attractive and homely place for short respite stays. EVIDENCE: Kathleen House comprises three separate bungalows set in well-maintained gardens, with ample off-road car parking in the grounds. The bungalows are purpose-built to provide a comfortable, home like and safe environment for younger adults to have enjoyable respite stays. Two of the visiting guests took it in turns to show the inspector around the bungalows. The exteriors and interiors continue to be maintained to high standards, with bright decor and interesting, attractive fixtures and fittings. The improvements since last visit include the replacement of the damaged work surface in the kitchen, 61, Addison Road and a new, very attractive and comfortable three-piece suite in the lounge at 61, Addison Road. During the tour of the premises a sample of guest bedrooms have been viewed. The bedrooms in each bungalow are colour co-ordinated, with red,
Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 19 blue, yellow and green themes. The two guests acting as escorts explained that they could bring their personal possessions with them for their visit. Two minor improvements are needed at this visit, to ensure bed guards are not left in place or alternatively beds are turned around to wall, for guests not requiring them; and the missing headboard in the blue room at 61 Addison Road must be replaced. Each bungalow has an assisted communal bathroom and communal toilets in addition to the bathing and toilet facilities in each en-suite bedroom. The bathrooms are clean, tidy and attractively decorated with stencils or seascapes. One minor improvement is needed at this visit; the perished and mould covered anti-slip bathmat at 61 Addison Road must be replaced. Each bungalow has a well-organised, well-stocked kitchen, which guests can use to make drinks and snacks, either alone or with staff assistance according to their risk assessment. The garden and grounds to the home are tidy and look very well maintained, especially at this autumnal time of year; this is mainly due to the time and attention given by a volunteer. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36 There is a stable well-trained staff team. Staff morale is high resulting in an enthusiastic workforce that works positively with guests to improve their whole quality of life. The home follows rigorous recruitment process, which safeguard vulnerable people. EVIDENCE: The staff at the home are well informed and well motivated and there is a good team spirit. All members of staff have an induction and structured probationary period, which is used to make sure that they are aware of their role and responsibilities. From assessment of the staff rotas there is evidence that the home is maintaining satisfactory staffing levels to meet the varying needs and varying numbers of guests accommodated during each week. A sample of staff personnel records examined is generally satisfactory. Improvements have been made since the last inspection visit and all staff personnel files now contain a recent photograph and a copy of the relevant job description. The personnel files of permanent members of staff also now include a copy of a signed contract / terms & conditions of employment, though this is not the case for bank staff. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 21 Formal and structured supervision sessions are now in place for each member of staff and the trainee manager uses a calendar to remind senior staff when staff supervision sessions become overdue. Remedial action is being taken to help people to catch up to achieve the target of six documented sessions every 12 months. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,40,41,42 The management of the home provides clear leadership and communication systems are generally very effective, staff are clear about their roles and responsibilities. The standard of records at this home is generally good, which provides safeguards for guests. EVIDENCE: Ms Hilary Jordan currently continues to be the Registered Manager, she is a Registered Mental Health Nurse (RMHN) and has the Registered Managers Award (RMA), through the Organisation’s accredited training centre, awarding body is City & Guilds. She has been in post since the Home opened in 1995 and has many years of valuable experience in developing and running the service. However over recent months she has increasingly taken wider responsibilities for new initiatives and line management at other homes. In recognition of her change of role a trainee manager has been appointed from within the staff team. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 23 This inspection visit has been mainly conducted with the assistance of the trainee manager, who was promoted from senior position at Kathleen House. To formalise responsibilities at Kathleen House the registered person must submit an application to the CSCI for the registration of the trainee manager within three months. Records at Kathleen House are generally very good and very satisfactory documentary evidence and the actions taken to improve the performance of staff, especially relating to the resolution of complaints and failures to maintain standards. However the CSCI has not received any Regulation 37 notifications relating to staff misconduct or disciplinary matters. There is documentary evidence on guest profiles that risk assessments have been reviewed and expanded to include all areas of risk associated with individual guests, such as moving and handling, challenging behaviours, falls, personal safety within the Homes environment and on any activities where the Home has a duty of care. The trainee manager is continuing progress to ensure that documented risk assessments and risk management strategies relating to the environment are reviewed, expanded and implemented. Minor improvements to health and safety have been identified during this visit, for example the first aid boxes at 59a and 61 Addison Road need to be restocked and monitored on a regular basis. A sample of fire safety and maintenance service records examined are satisfactory. There are a total of 14 recorded accidents involving guests and 2 accidents involving staff since 21 July 2005, however there is currently no regular accident analysis are taking place. There are outstanding requirements relating to the evidence to demonstrate the home is conducted on a viable financial footing. The Registered Proprietor has not to date made a copy of the last years audited accounts for Kathleen House and a business and financial plan to the CSCI Satellite Office, Halesowen, for consideration. Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 4 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 2 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X 2 2 X 3 3 LIFESTYLES Standard No Score 11 N/A 12 N/A 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 X 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Kathleen House Score X X X N/A Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 2 2 2 DS0000024949.V264278.R01.S.doc Version 5.0 Page 25 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. 2. Standard YA10 YA17 Regulation 17(1) 13(1) Requirement To obtain staff signatures to demonstrate awareness of the homes confidentiality policy To implement monitoring arrangements to ensure all guests dietary needs are appropriately catered for 1) To obtain a medication fridge thermometer and record the daily minimum and maximum temperatures - on order (Timescale of 31/03/05 and 31/08/05 Not Fully Met) 1) To ensure bed guards are not left in place (or beds are turned around to wall) for guests not requiring them 2) To replace the missing headboard in the blue room at 61 Addison Road To replace the perished and mould covered anti-slip bathmat at 61 Addison Road A copy of a signed contract / terms & conditions of employment - for all staff including bank staff
DS0000024949.V264278.R01.S.doc Timescale for action 01/01/06 01/12/05 3. YA20 13(2) 01/01/06 4. YA26 13(4) 23(2) 01/12/05 5. 6. YA27 YA34 16(2)(j) 17(2) Sch2 and 4 01/12/05 01/01/06 Kathleen House Version 5.0 Page 26 (Timescale of 31/08/05 Not Fully Met) 7. YA37 9(1) The registered person must submit an application to the CSCI for the registration of the trainee manager within three months 1) To provide documentary evidence that approved risk assessment awareness training has been arranged for all staff to be delivered within an identified timescale. (Timescale of 31/03/05 and 30/09/05 Not Fully Met) To ensure that Regulation 37 notifications are sent to the CSCI regarding staff misconducts / disciplinary sanctions 1) To restock the first aid boxes at 59a and 61 Addison Road 2) To resume the documented accident analysis on a regular basis To develop a business and financial plan, forwarding copies to the CSCI Satellite Office - Halesowen for consideration (Timescale of 31/10/04 and 31/08/05 Not Met) To send a copy of the last years audited accounts for Kathleen House to the CSCI Satellite Office - Halesowen. (Timescale of 31/10/04 and 31/08/05 Not Met) 10/02/06 8. YA42 13(4)(c) 23(2) 01/01/06 9. YA41 37(2) 01/12/05 10. YA42 13(4) 01/12/05 11. YA43 25 01/01/06 12. YA43 25 01/01/06 Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 27 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. 2. 3. Refer to Standard YA23 YA30 YA34 Good Practice Recommendations That staff signatures are obtained to demonstrate their awareness of the finalised multi-agency procedure for the Protection of Vulnerable Adults, issued by Dudley MBC That as and when washing machines are replaced, new equipment is compliant with requirements of standard 30 That staff signatures are obtained to demonstrate the receipt of their individual copy of the General Social Care Council (GSCC) Code of Conduct Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kathleen House DS0000024949.V264278.R01.S.doc Version 5.0 Page 29 - 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!
