CARE HOME ADULTS 18-65
Kathleen House 59-61 Addison Road Brierley Hill Dudley West Midlands. DY5 3RR Lead Inspector
Jean Edwards Announced 21 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 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 kathleenhouse 61@hotmail.com Mr. R. Murray 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) Ms Hilary Jordan Care Home 15 Category(ies) of LD Learning Disability (15) registration, with number of places Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service Users to include up to 15 PD and 15 LD, not exceeding the total number registered for. 2. No Service Users who are wheelchair users be accommodated at 59a Addison Road. Date of last inspection 10/01/05 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 E55 S24949 Kathleen House V225751 210705 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 conducted between the hours of 9.40 a.m. and 3.45 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and the homes progress in meeting 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 and support staff who were on duty. A number of records and documents were examined. 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. Since the last inspection in January 2005 the trainee manager has resigned. A new trainee manager has been appointed; she has worked at the home for many years as a senior worker. What the service does well:
The registered manager responded to the previous inspection report with a comprehensive action plan, which gave dates for the required improvements to be put into place. The majority of required improvements from the last inspection visit are now 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 E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 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. 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 gardeners skills and attention; the grounds and gardens look very well maintained, with neatly trimmed lawns, well-pruned trees and shrubs and attractive summer flowers. Kathleen House has 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 in trips away from the home. Staff demonstrate a dedicated approach to their work; they clearly know guests’ likes and dislikes and how to meet their needs. They answered any questions in an open and honest manner. This inspection was conducted with full co-operation of the Registered Manager, trainee manager and staff on duty. The atmosphere through out the inspection was 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 Registered Manager has introduced an annual planner to make sure that each persons needs are assessed and updated regularly. This is done for each stay, or as needs change, and at least 12 monthly as a minimum. Action has been taken to expand guests personal profiles, for example to include more detailed information regarding mouth care is provided for people who need artificial feeding. There are now fuller details of communication methods for people who have no verbal communication. In addition all members are staff completing daily records now sign them. Improvements have been put in place to make the storage and administration of any controlled drugs safer. The home has a comprehensive medication system, which makes sure there is continuity for each guests medication
Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 7 regime. During the previous visit the home was advised to make minor improvements in a small number of areas, the majority have been put in place. A further minor improvement is required at this visit to make sure that the administration of medication is as safe as it can be. The home has been provided with new carpets in all communal areas in the two bungalows: 59 and 61 Addison Road, since the last inspection visit, which improve standards for the benefit of guests. In addition all of the carpets in the communal areas of 59a, Addison Road have been steam cleaned. There have been improvements to control sources of possible infection or contamination. Changes have been made to the flooring make sure that all surfaces in the laundry areas are maintained with water impermeable finishes. Food safety has been improved with the replacement of the damaged extractor hood over the cooker in the kitchen, 61, Addison Road and a new front for the extractor hood for the cooker in 59a, Addison Road. Additionally new microwave ovens have been provided in the kitchens in 61 and 59 Addison Road. The organisation has reviewed and updated staff policies and procedures and staff contracts in view of the introduction of the protection of vulnerable adult abuse (POVA) register. The Registered Manager has put measures in place to make sure that the home reaches the target of a minimum 50 of care staff with an NVQ level2 or equivalent Learning Disability Framework award by December 2005. The home now has unannounced monthly visits from the organisations nominated representative on a consistent basis to monitor the homes performance. Written reports are now provided to the home and copies are sent to the CSCI satellite office, Halesowen. The Registered Manager has sent information to the CSCI office about accredited risk management training for all persons involved in undertaking risk assessments. Following the training some areas of risk have been looked at again and controls have been improved. For example risk assessments for beds where bed rails are used, have been expanded to take account of the type of mattresses used. Improvements have been made to health & safety at the home, weekly fire alarm tests are resumed on a consistent basis and regular monitoring and analysis accidents takes place, the Registered Manager has provided records of findings to the CSCI satellite office, Halesowen. Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 8 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. Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4,5 Information about the running and performance of the home is made proactively available and guests are encouraged to make their views known. The home has an updated contracts/terms and conditions of occupancy, this has the effect that guests and their advocates have good information regarding their rights and entitlements and any agreed restrictions. The home uses comprehensive assessment tools, which means that guests’ needs are thoroughly assessed to ensure that care needs will be met. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions, which are right for them. EVIDENCE: There is an up to date and comprehensive statement of purpose available at the home. There is evidence that guests and families residents are given a copy of the service user guide and there are signatures to demonstrate receipt in most instances. On examination of a sample of resident’s files the home has comprehensive assessment information and there is evidence of periodic reassessment as is good practice. The Registered Manager has devised a contract/statement of terms and conditions and this has recently been revised and updated to demonstrate compliance with the Office of Fair Trading guidance. Individual contracts now contain details of any agreed restrictions such as not going out unaccompanied
Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 11 or not smoking except in permitted areas. The sample of contracts/terms and conditions issued to guests / or their advocates, have been signed and dated. Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 6,9 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: Each guest has a comprehensive personal profile in place; new updated versions are being introduced, mainly for new people using the service. However one of the sample of personal profiles examined does not contain a completed signature sheet, signed by the guest and / or her supporter or advocate. The signature sheets are used to indicate agreement with the details in the personal profile, consent to medication and any other measures such as bed rails, though these are not necessary for this guest. 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. For example although one person currently visiting for a short stay has to be fed via a peg feed she can
Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 13 have a maximum of 10 teaspoons of pureed food daily, which she really enjoys and this boosts the quality of her life. The home receives training and support with her gastronomy care from the hospital, Nutritional Support Nursing Sister. 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. There is a comprehensive risk assessment system in place for each person. Specialist equipment is often brought into the home with individual guests to ensure continuity of care. There are detailed written instructions in place, especially for moving and handling people with complex physical needs, an example is the use of a Curtain chair and spiker. There are instructions how to position the person in bed and resting and exercise regimes. Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 13,15 Links with the community are good; these support and enrich guests social opportunities. EVIDENCE: Kathleen house is not able to evidence all of the National Minimum Standards due to the short stay, respite service provided. Standards 11 and 12 are not applicable to this home. Everyone using the service lives in the community supported in a variety of ways. Staff take care to offer support on an individual basis to people visiting Kathleen House to make choices about how they spend their time. Some people choose to continue with their planned programme of daytime pursuits, such as attending day care opportunities provided by the Local Authority. Other people choose to regard their stay at Kathleen House as a holiday and either stay at the home doing things that they enjoy or engage in the outings and activities arranged by staff at the home. The guests were all at day care opportunity venues or enjoying a day out shopping at the Merry Hill Centre during this visit. Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 15 The home has good communication with parents/carers; there is documentation on personal profiles, in the homes communication book. In addition good levels of verbal communications and personal contacts with families and other carers are maintained. Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 18,19,20 Personal support in this home is offered in such a way as to promote and protect guests’ privacy dignity and independence. The health needs of guests are well met with generally good evidence of multi disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure guests medication needs are met. EVIDENCE: Thoughtful examples of how guests’ privacy, dignity and independence is maintained. The home operates a key worker system, enhancing this aspect of care; this ensures each persons choice of how and when their personal care is achieved. There is documentary evidence of each persons preference as to the gender of staff to assist with personal care. Kathleen House supports each person’s health care needs as part of a continuum of the care provided for them whilst they are living with their families as part of the community. The Home provides staff support for attending appointments for people who are visiting for a respite stay. There is good evidence that residents continue to be encouraged and assisted to attend health care screening programmes such as well person checks.
Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 17 The Home has clear statements regarding situations where guests become ill during their stay; the family is contacted where possible and the person is discharged to their Home. The Home has comprehensive policies / procedures and systems relating to medication administration. All members of staff involved in the administration of medication have received accredited medication training and are rigorously assessed by the organisations training section. Guests’ medication needs are identified as part of the assessment process; parents or carers provide update information, documentary evidence was available on the sample of case files assessed. However the medication recorded for one person on an extended respite stay indicated Paracetamol on one document and aspirin on another. This persons medication for pain relief must be clarified. There are currently no guests at Kathleen House who administer their own medication. Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 18 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 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. There are flow charts in an innovative pictorial format, proactively displayed. These help guests to understand the process. The Home has received 3 complaints in the past 12 months, which have been appropriately investigated and resolved. The Home’s complaint log is satisfactory clearly identifying outcomes of investigations and actions. The home has comprehensive policies and procedures and staff training; relating to the protection of vulnerable adults, understanding abuse, whistleblowing, bullying, dealing with aggression from guests towards staff, use of physical intervention / restraint, and management of stress. The home has clear admission criteria and does not accept people behaviour, which challenges the service; and there is little or no challenging behaviour from guests. The Registered Manager continues to be part of a multi agency group implementing the Adult Protection procedures. This is now called the policy and procedure sub-group of Safeguard and Protect. There is a finalised copy of the Safeguard and Protect document available for staff guidance at the Home. Staff signatures should be obtained to demonstrate that they are aware of and have read the document. Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 19 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 standard(s) These standards were not assessed at this visit. EVIDENCE: Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35 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 Home has a staff team of 30 people including the Registered Manager and trainee manager. There is a separate maintenance team provided by the organisation. A new trainee manager has recently been appointed and was an active participant in this inspection visit. There are the equivalent of 24.5 full time workers and assessment of staff rotas demonstrates that the home is maintaining satisfactory staffing levels. There are records to show that staffing levels are regularly reviewed and revised according to the number and needs of guests visiting the home. Generally there continue to be 7 staff on each shift, 2 carers assigned to each bungalow, with a senior member of staff taking overall responsibility for the Home. Ten people have left the Home’s employ since July 2004 for valid reasons and currently there is one vacancy for 27 hours per week for a night carer. Existing members of staff working extra hours are covering the vacant post.
Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 21 The home operates the organisations standardised recruitment and selection process. The sample of staff files inspected are generally satisfactory, with employment checks actioned using a checklist. However there are no job descriptions on the files seen and one does not have a copy of the signed contract of employment. The most recently appointed member of staff does not have a recent photograph on her file. The Organisation has accredited training facilities, Charnat Care Training at Sylvan Green, which provide ‘guest’ specific training for all staff to ensure that they have a good understanding of the needs of the group of people they are caring for. The Home continues to demonstrate a strong commitment to training; there is satisfactory evidence to demonstrate it is on target with the strategy to ensure that a minimum 50 of care staff have achieved the NVQ 2 or equivalent LDAF award by December 2005. The home has an overall training plan and each person has an individual training profile. Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,41,42,43 The registered manager is supported well by her senior staff in providing clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. The systems for guest consultation at Kathleen House are good with a variety of evidence that indicates that guests’ views are both sought and acted upon. EVIDENCE: Ms Hilary Jordan is the Registered Manager and is a Registered Mental Health Nurse (RMHN), in addition she has the Registered Managers Award (RMA), through the Organisation’s accredited training centre, the awarding body is City & Guilds. The Manager has been in post since the Home opened in 1995 and has many years of valuable experience in developing and running the service. The trainee manager resigned his post to pursue a nursing career since the last inspection and a new trainee manager has been appointed from within the staff team.
Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 23 The home has a comprehensive internal quality assurance system, which involves audit visits by staff from other homes in the organisation. There are also other monitoring arrangements in place including unannounced monthly visits from nominated representatives of the organisation, with reports, which are given to the home and copied to the CSCI. These have recently resumed on a more consistent basis. The Organisation has achieved the Investors in People Award, which is regularly reviewed by external consultants. The Home is continuing to use the satisfaction survey with guests and families on an annual basis. The Home has included the outcome of the annual guest surveys in the revised service user guide Record keeping at the home continues to improve, achieving good standards, with only very minor improvements required at this visit. All personal information is held, stored and disposed of in accordance with the Data Protection Act 1998. A sample of fire safety and maintenance service records examined are generally satisfactory. The majority of issues identified at the previous inspection visit in relation to health and safety have been actioned. There were a total of 28 recorded accidents involving guests for the whole of 2004 and just 3 accidents involving guests between January and 21 July 2005 and there is good evidence available at this visit that a regular accident analysis are taking place. The Registered Manager and senior staff have undertaken risk management training and though there are plans to cascade risk assessment awareness training for all staff, this has yet to be delivered within an identified timescale. There are plans to review and expand as necessary, all areas of risk associated with individual guests including personal safety within the Home’s environment and on any activities where the Home has a duty of care. 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 E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 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 3 3 3 3 3 Standard No 22 23
ENVIRONMENT Score 4 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 x x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 N/A N/A 3 x 3 x x Standard No 31 32 33 34 35 36 Score x 2 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Kathleen House Score 3 3 2 N/A Standard No 37 38 39 40 41 42 43 Score 3 x 3 x 2 2 2 E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 25 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 6 Regulation 15(1) 17(1) Requirement To ensure that signature sheets are completed on admission with all guests / representatives to indicate their agreement with their personal profile, to medication and use of any measures such as bedrails 1) To obtain a medication fridge thermometer and record the daily minimum and maximum temperatures (Timescale of 31/03/05 Not Fully Met) 2) To clarify the discrepancy in the record of medication for GB, acertaining if it should be Paracetamol or Asprin. To ensure all staff personnel files contain: 1) A recent photograph 2) A copy of the relevant job description 3) A copy of a signed contract / terms & conditions of employment 1) To provide documentary evidence that approved risk assessment awareness training Timescale for action 30/09/05 2. 20 13(2) 31/08/05 31/07/05 31/08/05 3. 34 17(2) Schedules 2 and 4 4. 42 13(4)(c) 23(2) 30/09/05 Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 26 has been arranged for all staff to be delivered within an identified timescale. (Timescale of 31/03/05 Not Fully Met) 2) To ensure that all areas of risk associated with individual service users are clearly documented, such as moving and handling, challenging behaviours, falls, personal safety within the Home’s environment and on any activities where the Home has a duty of care. (Timescale of 31/03/05 Not Fully Met) 3) To ensure that documented risk assessments and risk management strategies relating to the service users and the environment are reviewed, expanded and implemented. (Timescale of 31/03/05 Not Fully Met) 4) To replace the damaged work surface in the kitchen, 61, Addison Road (Timescale of 31/03/05 Not Fully Met) To develop a business and financial plan, forwarding copies to the CSCI Satellite Office – Halesowen for consideration (Timescale of 31/10/04 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 Not Met) 5. 43 25 31/08/05 6. 43 25 31/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 27 No. 1. 2. 3. Refer to Standard 23 30 34 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 reciept of their individual copy of the General Social Care Council(GSCC) Code of Conduct Kathleen House E55 S24949 Kathleen House V225751 210705 Stage 4.doc Version 1.40 Page 28 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
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