Inspection on 23/05/05 for Kelvedon House

This inspection was carried out on 23rd May 2005.

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

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

Other inspections for this house

Kelvedon House 11/08/09

Kelvedon House 15/12/07

Kelvedon House 09/10/06

Kelvedon House 20/10/05

Kelvedon House 28/10/04

Kelvedon House 16/06/04

Kelvedon House 05/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Maple Lodge

Polesworth Group 32 Station Road

Heathlands

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kelvedon House 10 Clarkson Road Wednesbury West Midlands. WS10 9AY Lead Inspector Jean Edwards Announced 23 May 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. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kelvedon House Address 10 Clarkson Road Wednesbury West Midlands. WS10 9AY 0121 505 7775 0121 505 7775 kelvedonhouse@btconnect.com Mr. Sarwan Samrai 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) Julie Hill Care home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Date of last inspection 28/10/04 Brief Description of the Service: Kelvedon House is a Private Care Home, providing residential care and accommodation for up to eighteen frail older people. The Home is situated approximately a quarter of a mile from Wednesbury town centre, on main bus routes and close to the M6 motorway system. It is located close to easily accessible public transport routes to local areas and surrounding towns. There is limited car parking, two cars at the frontage, with some on road parking nearby. The accommodation is provided on two floors and consists of two double, and one en suite single and thirteen single bedrooms. There are two lounges and a dining area, eight toilets, three bathrooms and a shower. The Home has extensive gardens to rear of the premises, with some areas accessible to residents. There are no dedicated smoking facilities as such, though smokers at the Home may use the staff room or small greenhouse in the garden. The home does not provide intermediate care. There is the staff team of 21 people including 16 carers and the Registered Manager. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection visit was conducted between the hours of 9:00am and 5:10 pm. The purpose of the visit was to assess the home’s progress towards meeting the National Minimum Standards for older people and assess actions taken to improve areas highlighted at the unannounced inspection visit on 28th October 2004. A range of inspection methods were used to obtain evidence and form judgements, which included: assessment of pre inspection information supplied by the home; records of incidents, accidents and events; and reports of visits by the owner, submitted by the home prior to this visit. A range of records held at the home were examined. Interviews and discussions were held with the Registered Manager and members of staff who were on duty. A member of the senior staff took an active part in the inspection process. There was a tour of the building, looking in particular at communal areas of the home, the bathrooms, toilets, kitchen and laundry areas, and a sample of residents’ bedrooms, with their permission, one person refused. There were 17 people at the home, one person was in hospital. During the visit the inspector spoke to the majority of residents. Longer discussions took place with the residents whose care was looked at in depth. Discussions took place with relatives who were visiting and were happy to give their views. They stated that they were always made welcome by the staff who were friendly, helpful and courteous. Survey comment cards were sent to the residents and relatives from Commission for Social Care Inspection (CSCI), 14 were returned. The majority expressed positive or generally satisfied views, though half commented that there were not enough activities of interest and a smaller number were not satisfied with the meals. What the service does well: The Proprietor and 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 registered manager is committed to making sure that improvements happen, where she has the authority to make decisions. The Registered Manager makes sure that each persons needs are identified and understood before they are admitted to the home. All of the important and relevant information held by social services and the health service about the person is obtained to make sure the home can meet their needs. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 6 Residents and their families are encouraged to be actively involved in planning the way that care is provided. Full details of each person’s likes and dislikes, preferred routines, hobbies and interests are recorded in a care plan. Review meetings involving families are regularly held to discuss the care being provided and to monitor the resident’s well being. A relative commented “everything is as it should be - its good - dad is happy and comfortable - we can discuss anything with the manager and the owner”. Residents are encouraged by staff to treat Kelvedon House as their own home and to be as independent as they wish. Staff are caring, committed and flexible, often willing to work extra shifts. One resident who had lived at home for about two years stated, “the caring ladies are very nice -cant do enough for you”. Another resident recently admitted to the home confided “I was concerned at first because its a new place for me - but have settled and like it now” There was a lot of friendly chatting between staff and residents through out the day with a warm and genuine rapport. This inspection was conducted with full co-operation of the Registered Manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. Kelvedon House is generally clean, tidy, homely and comfortable. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection? There is an improvement to the information about the services offered by the home. Written information is now proactively made available to residents and families when they first come to the home. A new resident admitted to the home on the Friday evening before this inspection visit, commented that she was “pleased to see the information about things to do at the home and trips and outings, - likes to be occupied and to get out – doesn’t want to spend time sitting around on her bottom”. Efforts have been made to improve the way medication is stored, administered and recorded, though further minor improvements are needed. For example fuller details of times and dosages of medicines must be obtained from a reliable source at the time a new person comes to stay at the home. Some residents commented that meals have improved and the Manager is conducting anonymised surveys relating to the levels of satisfaction with food. There are laminated menus provided on each table, which are laid with attractive clean crisp red table-cloths ready for mealtimes. The Registered Manager regularly reviews areas of the home which need to be repaired or redecorated, as interim measures, until building work on the new home commences. Bathroom 3 has recently been redecorated, making it much Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 7 brighter. Considerable efforts have been made to keep the home as clean as possible, with noticeable improvement to the upstairs corridor carpets. Good progress has been made to provide the staff with training to enable them to improve their understanding of the needs of the residents. The home has met the target of 50 of care staff with an NVQ 2 qualification. The Proprietors are proposing to build a new 54-bedded home within the existing site and have given a commitment to continue discussions with existing residents and families. The approximate date for completion of the new 54 bedded home is January 2006. The Registered Manager has set up regular meetings with residents to give them the opportunity to have a say in the running of the home. There are notes of these meetings, which are publicly available. 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. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Progress has been made to update contracts/terms and conditions of occupancy, though further minor additions are required. This has the effect that residents and their advocates do not have sufficient information regarding their rights and entitlements and any agreed restrictions. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. Introductory visits are encouraged by the home and there is documentary evidence to demonstrate that people have been given the opportunity and time to make decisions which are right for them. Standard 6 does not apply; this Home does not provide intermediate or respite care. EVIDENCE: The Proprietors and Registered Manager have revised and updated the homes statement of purpose and service user guide, which are now produced in an attractive format. The sample is due to be published and distributed. Each person has a contract / terms and conditions, which is appropriately signed and dated. One family member has taken the opportunity to note several comments and queries on the document. Although the contract / terms Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 10 and conditions has been revised and updated further minor adjustments are required, such as who will be responsible for paying the fees and what will happen if there is a breach of contract by either party. Examination of a sample of residents’ case files demonstrates that the home has obtained the referral agency’s assessment of needs and in most cases a care plan. There are copies of Sandwell Authority’s single assessment information for people admitted from the Sandwell area. In addition the home has a comprehensive assessment tool, which is completed with all relevant information. Evidence from informal discussions with residents and families is that the home does offer an opportunity to visit before an admission takes place, and there is now documentation relating to introductory visits. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 There is clear and consistent care planning with monitoring in place to adequately provide staff with the information they need to satisfactorily meet residents needs. The health needs of residents are generally satisfactorily met with some evidence of good multi disciplinary working taking place on a regular basis. The home has made good progress with regard to the arrangements for administration of medication, which safeguards the well being of people living at the home EVIDENCE: Each resident has a care plan in place, and all of the sample of plans examined had been signed by the resident and / or their family or supporter. During discussions with one of the residents whose care was tracked during this visit; and with a family member they, confirmed that there is an active involvement in developing and implementing plans for their care. Most residents spoken to are aware of their key workers and allocated senior’s name. This information is displayed inside their bedroom door and recorded in their care plan. Of the care plans examined there was some variance in content. The plans generally contain a considerable amount of information, which is well presented. The most recently admitted resident (Friday 20th May 2005) had a partly completed care plan in place, though all care needs were identified as Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 12 part of the assessment process. A resident admitted in March 2005 has medication for pain relief and has received a continence assessment and has been prescribed continence aids. However these care needs are not currently detailed in the care plan. Daily records are completed on a shift by shift basis, however entries are very basic. These need to be developed to reflect the level of support provided, with information as to the way each persons care needs are being met and progress to achieving short and long-term goals. There is evidence that the majority of elements of care plans are formally reviewed on a regular basis, involving relatives, advocates and other professionals wherever possible. The Registered Manager strives to ensure that professionals such as social workers are formally invited to participate in this process. However with the exception of one social worker from Sandwell Social Services Department, reviews take place without the support of placing agencies. Improvements have been made to the medication system as a result of requirements issued at previous inspection visits, with records of the administration of medication and monitoring arrangements now generally satisfactory. There is evidence of guidance for staff relating to the administration of PRN medications and any special instructions, such as administration for one person - half an hour before food. Accredited medication training for all staff involved in handling medicines is planned to commence in June 2005 provided by Dudley College. Interim medication training has been provided by the contracted pharmacist. Records examined showed that on occasions medicines have not been administered because insufficient supplies of medication had been received. Arrangements must be put in place to ensure that all residents receive medication as prescribed. During discussions staff were knowledgeable about each persons needs and preferences particularly in relation to their privacy and rights to make choices. Throughout the visit staff were seen to communicate well with the residents. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 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) 12,13,15 Although there has been some progress to make planned and spontaneous activities available on a regular basis, not all residents are able to take advantage of and develop socially stimulating opportunities. There continues to be good contact maintained with family and friends for the majority of residents. Dietary needs of residents are catered for inconsistently even though a balanced and varied selection of food that meets residents’ tastes and choices is available. This potentially places some people at risk. EVIDENCE: There is a weekly activities programme displayed on the notice board in the main lounge / dining area. Residents spoken to confirmed that, whilst there are sufficient staff on duty they do not always have enough time to spend talking to them or to provide regular activities or outings, as advertised. The home has a range of board games available and recently some outings have taken place for example to Lichfield Cathedral and Bridgnorth, with a further visit to Blist’s Hill Museum planned. A range of views were expressed, one person chooses to go on trips depending on the destination, length of trip and comfort on the minibus. Someone else had very much enjoyed the trips and another person felt there needed to be more thought about facilities at the destination and staff support for the number and capabilities of people going on the trips. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 14 The home has a 4-weekly menu, which offers a varied choice of meals. The previous requirement to produce the menus in appropriate formats has been met with the provision of individual laminated menus for each table. These are more appropriate to the residents’ capabilities, giving them the opportunity to be aware of the choices available. Menus have recently been revised as a result of discussions held in residents meetings. Alternative options have been introduced such as curries, spaghetti bolognaise, and chilli con carne, which are well liked. The Registered Manager is using anonymised feedback cards for some residents to complete after the main meal each day, she is analysing and collating results and continuing discussions with residents. For example when residents were not happy with the meat (liver) provided, she took action to remedy this. The home has recruited a qualified chef, who will commence work as soon as all the pre-employment clearances and checks are received and satisfactory. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 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 The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. Policies, procedures, guidance and staff training need to be implemented in order to provide residents with more safeguards from abuse. EVIDENCE: There have been no complaints recorded in the home’s complaints log since the last inspection visit in October 2004. A complaint sent directly to the CSCI office, Halesowen prior to the unannounced inspection was investigated as part of the last visit. The complaint was partly upheld and appropriate action has been taken by the Manager. Some residents spoken to stated that they feel that they can voice any concerns either through their meetings or directly with the manager or staff at the home. There were other residents who are more apprehensive about what might happen if they raise concerns. The Proprietor and Manager must ensure that all residents and families feel secure about voicing concerns, without any fear of repercussions. The manager and staff are aware of the local authority multidisciplinary procedure for the protection of vulnerable adults. The Registered Manager has recently purchased training materials from an external training organisation. This is a distance learning package consisting of videos and workbooks, which will be externally assessed. Progress must continue to equip all staff with appropriate levels of training to ensure that they are aware of and are able to respond appropriately to situations which require them to take action relating to the protection of vulnerable people. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 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) 19,21,24,26 The manager has a good understanding of the areas where the home needs to improve and some proactive planning is now in place indicating how this improvement is going to be resourced and managed. These are interim measures until the new building is completed. The standard of the décor within this home is generally acceptable with evidence of some improvement through general maintenance and redecoration. This is a small home presenting as a homely and comfortable environment for residents. People living at the home are protected by the good infection control measures which are in place. EVIDENCE: The Registered Manager has a documented program for the ongoing maintenance and redecoration of the home, with good awareness of the minor works which need to be completed until the replacement home is built. Since the last inspection visit work has continued to improve the communal bathing facilities, with bathroom 3 redecorated to provide a lighter cleaner environment. During the tour of the home some of the resident’s bedrooms were viewed, with each persons permission. One person refused stating she had not had Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 17 time to sort her room out and didnt want it seen. Some residents chose to act as escorts to their own bedrooms. People are able to personalise their own rooms as they wish. Inventory records are held on each person’s file. One person with limited wardrobe and draw space is storing some clothing and personal items in cardboard boxes in the bedroom. The home must provide sufficient storage for clothing and personal possessions to meet each persons needs. The standards of cleanliness in the home have improved, particularly the corridor carpets, which are faded and were heavily soiled. Efforts need to continue to achieve a pleasant environment and adequate infection controls to safeguard the residents. There are outstanding requirements relating to the laundry area, which is recognised will only be resolved with either the new build, due to take place by January 2006, or the refurbishment of the existing laundry. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 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) 27,28,29,30 Progress has been made in addressing substantive staffing levels and residents generally receive consistent care. Since the last inspection the standard of vetting and recruitment practices has improved with appropriate checks being carried out. Good progress is being made to provide all staff with training, which will provide safeguards for residents. EVIDENCE: The home has a team of 22 people including the Registered Manager and 16 carers. Two people have left the home’s employ since the last inspection visit in October 2004. The home currently has one vacancy for a carer on days for 21 hours each week. Assessment of staffing information including staff rotas, shows that the home is currently providing adequate staffing levels. There are records for all staff working at the Home and the staff files for new and existing staff are well organised. These contain an improved level of the information needed to make recruitment and retention processes robust. There is a formal supervision system, however the number of formal supervision sessions must be increased to ensure that all care staff receive a minimum of six documented supervision sessions each year. The registered manager is making good progress to access and provide appropriate training for all members of staff. The home has achieved the target of 50 of care staff trained to NVQ level 2; and there is a comprehensive training plan in place. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 19 Residents and visitors consulted during the visit spoke warmly about the staff, referring to their helpfulness and kindness. They were pleased that there were more staff about, though some residents stated that staff were still very busy at times. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 20 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) 31,33,36,37,38 The registered manager is supported by her senior staff in providing clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. The home is making progress to regularly review aspects of its performance through a good programme of self-review and consultations, which include seeking the views of, residents and relatives, staff and other professionals. The systems for resident consultation at Kelvedon House have improved with a variety of evidence that indicates that residents’ views are both sought and acted upon. EVIDENCE: The Registered Manager, Julie Hill, has worked at Kelvedon House for approximately 2 years and has achieved the Registered Managers Award (RMA). In addition she is an NVQ work-based Assessor and has also attended an approved risk management training course to effectively promote the management of risks and health and safety at Kelvedon House. There are plans to cascade risk assessment awareness and training for the whole staff group, though there is no date as yet for this to take place. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 21 There are good arrangements in place to ensure that residents are consulted about the day to day running of the home. For example, there are regular and recorded residents meetings, organised and run by the Registered Manager, with a wide range of topics discussed. The date of the meetings and agenda is displayed as a poster 3 weeks prior to the meeting. Plans related to the proposed new building are displayed in the home. There are plans to arrange formal consultation meetings with existing residents, relatives and representatives when building tenders have been submitted and selected, due in the next month. The approximate date for completion of the new 54 bedded home is January 2006. The home has yet to implement a comprehensive quality assurance system. However there are a number of monitoring arrangements in place including unannounced monthly visits from the Proprietor, with reports which are given to the home and copied to the CSCI. In addition the home has given a signed undertaking to achieve the Investors in People Award. A sample of fire safety and maintenance service records were examined, these are generally satisfactory. The home must forward documentary evidence of up to date refresher fire training sessions and fire drills for all staff, to the CSCI office, Halesowen. There are 18 recorded accidents involving residents since the visit on 28 October 2004. There is documentary evidence available at this visit that a regular accident analysis has taken place, with action taken when needed. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 22 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 x 3 x x 2 x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 2 x x 2 2 2 Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 23 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 1 Regulation 39(e)(i) Requirement Timescale for action 30/06/05 2. 2 5(1)(c) To forward confirmation to the CSCI Satellite office full details of the change of company name, address, officers etc. (Timescale of 30/11/04 is not met). 31/07/05 To review the contract / terms and conditions using the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Homes (Timescale of 31/12/04 is partly met). To expand existing contracts/ terms and conditions to include: responsibility for paying fees and breaches. To ensure service user plans 30/06/05 include: 1) Agreed limitations on choice, freedom or decision-making (Timescale of 1/12/04 is partly met). 2) All of the care needs identified during the assessment or review processes, for example management of pain relief, continence, tissue viability To provide fuller details in 30/06/05 residents daily notes to reflect how care needs have been met Version 1.30 3. 7 15(1) 4. 7 37 15 (1) 17 (1) Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Page 24 5. 9 13 (2) and evaluate whether short/long term goals are being achieved 1) To provide documentary evidence that medication training for all staff responsible for administration of medication has been officially accredited. Planned to be action through an accredited training course. (Timescale of 1/12/04 is partly met). 2) To ensure full details of medication regimes are obtained at the point of admission, to include dose, form, time of administration. 3) To request a medication review by the GP for the person prescribed Olanzapine. 4) To ensure that adequate supplies of medication are ordered and available for each resident to be able to receive correct dosages to meet their needs, for example Paracetamol, Lactulose To resume the practice of recording participation in activities on an individual basis, noting refusals and evaluating successes. 30/06/05 6. 12 16(2)(m) (n) 30/06/05 7. 15 16(2)(g) (i) To review residents preferences regarding activities, taking action to revise the activities programme as necessary, the documentary evidence. 30/06/05 1) To ensure that service users receive food portions sizes according to their preferences (Timescale of 30/11/04 is partly met). 2) To employ sufficient appropriately experienced and skilled catering staff to ensure a Version 1.30 Page 25 Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc 8. 16 18(1)(c)2 2 13(5)18(1 )(c) 9. 18 10. 24 23(2)(m) 11. 26 16(2)23(2 ) 17(1)(2)S chedules 2 and 4 12. 29 13. 30 38 13(4) 18(1)(c) 23(5) nutritious diet for all service users (Timescale of 30/11/04 is partly met). 3) The registered manager must continue to undertake documented consultations with residents regarding levels of satisfaction with meals provided 4) Provision of adapted eating utensils and plate guards must be made available, as needed, to assist residents to eat independently To ensure all staff receive up to date complaints awareness and training (Timescale of 31/12/04 is partly met) To provide appropriate staff awareness and training regarding protection of vulnerable adults (Timescale of 31/12/04 is partly met) Additional storage for clothing and other personal possessions must be provided for the resident (BD) and any other resident with insufficient storage. To provide separate hand washing facilities for staff in laundry area. (Timescale of 1/12/04 is not met). To continue with the process of obtaining all information required for staff files to meet the documentation identified in Regulation 17(1) Schedules 2 and 4. (Timescale of 1/12/04 is almost met). 1) To ensure ALL staff employed have up to date mandatory training as follows; fire training & drills x 2 each year, (by 31.7.03); moving & handling, infection control, with documentary evidence of completion. (Timescale of 31/12/04 is partly met). 30/06/05 31/07/05 30/06/05 31/07/05 30/06/07 31/7/05 Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 26 14. 36 18 (1) (c) 15. 38 13 (4) 2) To forward documentary evidence of refresher fire training provided for ALL staff to CSCI office, Halesowen Registered manager must ensure 31/07/05 that all care staff received as a minimum six documented structured supervision sessions in any 12 month period 1) To provide documentary 31/07/05 evidence that approved risk assessment awareness training has been arranged for all staff to be delivered within an identified timescale. (Timescale of 1/12/04 is partly 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 Homes environment and on any activities where the Home has a duty of care. (Timescale of 31/01/05 is partly met) 3) The Registered Manager must ensure that there is a documented risk assessment in place prior to any trip or an outing for the residents, with an appropriate number of adequately trained and experienced staff to meet the needs of residents participating; in addition to individual risk assessments for each resident for that particular activity 4) To ensure that documented risk assessments and risk management strategies relating to the service users and their environment are reviewed, expanded and implemented. Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 Page 27 (Timescale of 31/01/05 is partly met) 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 27 Good Practice Recommendations That an annual schedule of staff meetings is devised and displayed to ensure that a minimum six staff meetings take place each year and that staff have the opportunity to plan their attendance That an annual schedule of staff supervision sessions and annual appraisals is devised and displayed to ensure that all care staff have a minimum six formal supervision sessions and an annual appraisal each year 2. 29 Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 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 © 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 Kelvedon House E55 4847 Kelvedon House 221345 230505 Stage 4.doc Version 1.30 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!