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Inspection on 23/09/08 for Lady Forester Residential & Day Care Centre

Also see our care home review for Lady Forester Residential & Day Care Centre for more information

This inspection was carried out on 23rd September 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a committed team of staff who work hard to meet the needs of the people they support. They are professional and respectful when caring and supporting the people living at the home. People are able to have flexible daily routines and told us they can come and go as they please. The home is clean and comfortable.

What has improved since the last inspection?

Medication administration procedures are improved and the home manage this in a safe way.

What the care home could do better:

The manager is keen to develop the service and raise the standards of care people can expect to receive in line with national minimum standards and good practice. There are a number of areas she will need to develop to achieve this goal which were fully discussed at the key inspection. The home must only admit within the category of registration and only if the service is confident that staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. The home`s statement of purpose and service user guide are currently being reviewed and should be issued to all prospective service users upon admission. People who choose to move into the home should be given a contract/terms and conditions of residency and should know what to expect from the service.The home needs to develop the assessment and care planning process to show how it has consulted with people at the time of their admission to the home and on an ongoing basis. Care plans need to contain more specific details on the care needs of individuals and how they wish those needs to be met. The manager must report all incidents of safeguarding through the safeguarding of adults process. To support her understanding of how to manage safeguarding issues it is recommended that she attend the managers protection of vulnerable adults training. There should be sufficient numbers of staff on duty at all times to meet the needs of people using the service and they should be reviewed by the manager as the needs of individuals change. It is recommended that there is a review of the number of domestic hours provided to keep the home clean and tidy. The complaints procedure should be reviewed and made available to all people living at the home and prospective service users. The home should implement an effective quality assurance system based on seeking the views of people using the service, their representatives and other interested stakeholders to measure their success in meeting the aims, objectives and statement of purpose of the home. Policies and procedures that were sampled at the inspection have not been reviewed for some time. The manager acknowledged the need to update these including the handling of money and valuables. Product safety data sheets should be obtained for all hazardous substances used within the home. The manager must make an application to CSCI for registration.

CARE HOMES FOR OLDER PEOPLE Lady Forester Residential & Day Care Centre Church Street Broseley Shropshire TF12 5BQ Lead Inspector Karen Powell Key Unannounced Inspection 09:15 23rd & 24 September 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lady Forester Residential & Day Care Centre Address Church Street Broseley Shropshire TF12 5BQ 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) 01952 884539 01952 884552 Lady Forester Residential & Day Care Centre Post vacant Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th April 2008 Brief Description of the Service: Lady Forester Residential and Day Care Centre is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care to a maximum of eleven elderly people. Ten rooms are provided for permanent service users and one bed is provided for respite purposes. The home is situated on the outskirts of Broseley, Shropshire and set in well maintained grounds. The building was formerly the Cottage Hospital. The centre is a charitable organisation and managed by a board of Trustees. The home is situated on the ground and first floor of the centre, which is accessible via a passenger lift. Two small quiet rooms are situated on the ground floor. All bedrooms are single. Day Care is provided three days a week on the ground floor and people living at the home are able to participate in activities arranged by day care staff if they wish to do so. The manager is Trish Cornes who has been in post since 18th August 2008, she has previously been registered with CSCI when she managed older peoples services prior to taking up this post. People can obtain information about this service from the home’s Statement of Purpose and Service User Guide. The reader is advised to contact the home to obtain up date information on the fees charged. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is zero stars. This means that people who use this service experience poor quality outcomes. One inspector carried out the inspection over two days over a period of eleven hours. A range of evidence was used to make judgements about the service to include discussions with some people who use the service, staff on duty, the manager and previous interim manager who up until recently had held the position of manager in the interim period of a manager appointment. We did a tour of the home, reviewed the homes quality assurance processes and observed the care experienced by people using the service. A number of records were reviewed to include care records held on behalf of three people, complaints and protection, staff training, recruitment and health and safety records. The last key Inspection in December 2007 identified shortfalls relating to the health, safety and welfare of people living in the home. Since the inspection in December we have conducted a random unannounced inspection to the home in April 2008. We found that the home had worked to address the shortfalls and had met four out of the five requirements made. This inspection identified serious concerns relating to the admission of people to the home along with safeguarding of adult issues. As a result of this the home had to take immediate action to safeguard one individual in particular. This involved an urgent mental health and social care assessment of their needs being undertaken in order to secure an appropriate place for them to live. Three people who live in the home were ‘case tracked this involves establishing individuals experience of living in the care home by meeting them, discussing their care with staff, looking at care files and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was sent to the manager for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 6 they are doing well. By law they must complete this and return it to us within a given timescale. The inspection reviewed all twenty-two of the key standards for care homes for Older People, standard 36 and the one outstanding requirement made at our last key inspection. Information to produce this report was gathered from the findings on the two days and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. What the service does well: What has improved since the last inspection? What they could do better: The manager is keen to develop the service and raise the standards of care people can expect to receive in line with national minimum standards and good practice. There are a number of areas she will need to develop to achieve this goal which were fully discussed at the key inspection. The home must only admit within the category of registration and only if the service is confident that staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. The home’s statement of purpose and service user guide are currently being reviewed and should be issued to all prospective service users upon admission. People who choose to move into the home should be given a contract/terms and conditions of residency and should know what to expect from the service. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 7 The home needs to develop the assessment and care planning process to show how it has consulted with people at the time of their admission to the home and on an ongoing basis. Care plans need to contain more specific details on the care needs of individuals and how they wish those needs to be met. The manager must report all incidents of safeguarding through the safeguarding of adults process. To support her understanding of how to manage safeguarding issues it is recommended that she attend the managers protection of vulnerable adults training. There should be sufficient numbers of staff on duty at all times to meet the needs of people using the service and they should be reviewed by the manager as the needs of individuals change. It is recommended that there is a review of the number of domestic hours provided to keep the home clean and tidy. The complaints procedure should be reviewed and made available to all people living at the home and prospective service users. The home should implement an effective quality assurance system based on seeking the views of people using the service, their representatives and other interested stakeholders to measure their success in meeting the aims, objectives and statement of purpose of the home. Policies and procedures that were sampled at the inspection have not been reviewed for some time. The manager acknowledged the need to update these including the handling of money and valuables. Product safety data sheets should be obtained for all hazardous substances used within the home. The manager must make an application to CSCI for registration. 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. The summary of this inspection report can be made available in other formats on request. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Quality in this outcome area is poor. The assessment procedure has not been followed in line with the home’s policy and has potentially placed people who use the service at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new manager has begun to review the information that the home provides to prospective service users. She was able to give us a copy of the revised statement of purpose, however she had not completed the review of the service user guide. A full analysis of the documents therefore could not be undertaken and will be fully reviewed at the next inspection of the service. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 10 We looked at the records of two individuals admitted to the home since the last inspection. One individual had moved into the home from out of the area. Information about this individual had been gained from discussion with a relative over the telephone. Whilst the person wishing to move into the home lived some distance away, which would make a visit by the manager to carry out an assessment difficult, information about the individual had not been gained from any professional who might have known the person. There had been no assessment of the individuals needs requested from their local social services department. The second individual we case tracked was recently admitted to the home by her GP and the care home manager. Information documented as part of the assessment concerned us that the home had admitted this individual outside of the category of the homes registration. Observation of this persons needs, discussion with the individual and discussion with care staff confirmed that the home could not meet the needs of this person and immediate action was required to safeguard the individual concerned. The manager must ensure that the assessment procedure is followed and takes into account the registration category. The service needs to ensure that the home is confident that staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. Terms and conditions for both individuals were not satisfactory and did not include information about the room they would occupy and any additional services that are not included in the weekly fees. Both individuals had been admitted as respite stays which had been made permanent. Contracts did not reflect this arrangement. Contracts are in need of reviewing as a matter of urgency. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. People who use the service have a care plan and some risks to individual safety are identified; however further attention is needed to ensure staff are provided with accurate and up to date information to meet people’s needs safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People spoke to during the inspection told us they are well looked after. On the day of the inspection it was observed that the doctor had been in to visit one person living at the home and the district nurse had also attended to another person living at the home. We looked at the care files of three people living at the home. Although care plans contained basic details they lacked specific details which would provide staff with guidance as to how people want their needs met and the action Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 12 needed by staff to meet those needs. For example there was no guidance in place for dealing with behaviours that might be threatening or challenging. Risk assessments were not in place to protect people using the service or staff delivering care and/or support to individuals. In the case of one individual, although a referral to the psycho geriatrician had been made the day after their admission two weeks before CSCIs visit, the home had failed to access urgent medical intervention due to the challenging behaviour this person was presenting. The care plan or risk assessment did not reflect this individual’s needs satisfactorily. The three care plans looked at showed no evidence that residents or their representatives are involved in planning or reviewing their care. During this inspection we looked at medication procedures and found these to be in line with current good practice. The requirement from the previous inspection which stated all items of medication must be entered onto the MAR sheet exactly as instructions appear on the original packaging, to ensure carers are clear about correct medication times was considered to be met. Administration of medication is only carried out by carers who have undertaken the safe handling of medication training. Throughout our visit we observed staff to be respectful towards individuals living at the home. People we spoke to told us their privacy and dignity is maintained at all times by a caring staff group. People confirmed that their mail is given to them and unopened at all times. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home can access the day centre where activities are provided. The day centre is open three days a week. On the day of the inspection the day centre was closed, however people were seen using the area. People use the area to gather and chat, one lady was seen knitting. It was observed and confirmed through discussion with staff that unless people use the day centre there is little opportunity for the homes staff to undertake activities with people living at the home due to time restraints. One person who we case tracked told us that they can do very much what they wish. They told us that their routine is flexible and that there were no rules or Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 14 restrictions imposed upon them by the home. They told us that their relative visits on a regular basis and they are able to see them in private in their bedroom. This was repeated to us from other people we spoke to during the inspection. We observed people to be relaxing watching television in their bedrooms and accessing the day centre to socialise. It appeared through menus seen, discussion with people using the service and observation of the lunchtime meal that food provision is good. Lunchtime was seen to be a relaxed occasion, with staff assisting people where required in a dignified way. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. There is a complaints policy in place but this does not meet national minimum standards. People who use the service are not protected by robust policies, procedures and practice relating to adult protection. This places people who use the service at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy, however this does not meet national minimum standards and is in need of review. It was confirmed by the manager that to her knowledge there have been no complaints made to the home since the last inspection. CSCI have received no complaints since the last inspection. The home has a copy of the local multi-agency safeguarding adult policy and procedure. Staff receive training in the topic abuse and safeguarding adults and it was clear through discussion with staff that they are aware of issues that should be reported to the manager. Evidence showed in one particular case that staff had reported an incident of concern to the manager. This incident was clearly a safeguarding issue that should have been reported by the manager through the local authority safeguarding adults process. We had serious concerns about the admission of this individual as reported in outcome Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 16 group choice of home and initiated an urgent referral for a assessment to the local social services department. The manager was requested to report the safeguarding incident to the local authority safeguarding of adults process on the day of the inspection. We also made an alert to the local safeguarding adults team. The manager has undertaken training in the topic of abuse and safeguarding of adults, it is recommended that she attend the protection of vulnerable adults managers training. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. The home enables people to live in a safe, well-maintained and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is maintained to a good standard. This is currently undertaken by the care staff for the upstairs of the building and a cleaner who works two hours a day Monday to Friday. It is recommended that these hours be reviewed to free up the care staff to undertake their duties as required. People we spoke to said they were happy with the standard of cleanliness and that they were happy with their personal space. Communal areas are furnished well and to a comfortable standard. There are two small communal quiet Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 18 rooms along with the day centre area, which provides space for people to come together for entertainment and activities. The home has a private garden, which is well stocked with shrubs and flowers. We looked at the individual bedrooms of the people we case tracked, which were personalised with peoples own possessions and familiar items. Furniture and specialist equipment is provided to ensure individual’s needs are fully met and to maximise their independence. Staff were observed to follow good infection control procedures to minimise the risk of infection within the home. The home has submitted an application to us for the registration of three additional rooms, which is currently being processed. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. Staff work positively and are equipped with the necessary training. However staffing levels were not sufficient in numbers to effectively meet the needs of the people accommodated at the home. Recruitment procedures safeguard the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken to and training records examined demonstrated that the home support individuals to attend training to equip them with the knowledge and skills in order to carry out their role. Mandatory moving and handling training is due to be updated for all staff and a course is booked to take place in the near future. Staff were polite and courteous throughout the day to people living at the home. People spoken to us said the staff are very patient the staff are kind and caring I am looked after well Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 20 As reported earlier in this report the home had admitted an individual that they were not registered to take. The challenging behaviour of this individual impacted greatly on the staffs time and ability to provide care and support for all of the people living at the home at the time of the inspection. We had concerns about the challenging needs of this individual, their safety, the safety of other people living at the home and the safety of staff working at home. We discussed our concerns with the manager and asked her to immediately review the staffing levels to increase the numbers of staff on duty across the 24-hour period. This was acted upon immediately until the individual was reassessed and moved on from the home shortly after our inspection. It was reported by the manager that there had been no new appointment of staff since the last inspection. It was considered at the last key inspection in December 2007 that the home operated a robust recruitment procedure. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is adequate. Frequent change in managers over a short period of time has resulted in an inconsistent management approach, lacking consistency in management systems and development of the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has recently appointed a new manager on 18th August 2008 following the resignation of the previous manager. The service has had a number of managers over a relatively short period of time, which has had an impact on staff morale, and the development of the service. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 22 The current manager has experience of managing care homes but not a domiciliary care service. She acknowledges that this is quite a challenge and is currently able to complete the rotas for the care agency but has not had the opportunity to begin to learn about the requirements of the domiciliary aspect of the service. Ms Cornes has previously been registered with CSCI. She holds the registered managers award, NVQ 4 in care and has undertaken all her mandatory training. She has not submitted an application for registration to CSCI and is aware of the requirement to do so. Through discussion with the manager she has already identified some areas in need of development within the care home and had read the last inspection report before attending for her interview. She is very keen to raise standards within the home in order to comply with national minimum standards. It was disappointing to find that the manager and the former interim manager had admitted someone outside of the category of registration and furthermore had not promptly addressed the situation presented to them as a result of their decision to admit this person to the home. The home does not have an effective quality assurance policy in place to seek the views of people who use the service, their representatives or interested stakeholders in the care home. It is important that the service put systems in place to measure their success in meeting the aims, objectives and statement of purpose of the home. People using the service are encouraged to manage their own finances. Where the home does hold small amounts of money for some people it keeps the computer record. We advised the manager and administrator to obtain two signatures for all transactions, and maintain a paper copy of the financial records. An agreement for money held on behalf of the individual should be obtained and how this is managed should be clearly documented in the persons care record. A discussion regarding the review of the handling of peoples money and valuables policy and procedure took place with the homes manager and administrator. This is to ensure that a clear audit trail is put in place to safeguard people using the service and staff who are handling many or items placed in safekeeping. We have received notification from the homes administrator that the matter had been addressed and procedures reviewed as an outcome of the inspection. Although staff reported they have received supervision, records relating to this showed that it has not been given at the required frequency. A sample of maintenance records required for health and safety appear to be satisfactory and routine maintenance checks have been carried out. On a tour of the building cleaning products found outside the locked control of substances hazardous to health (COSHH) cupboard did not have safety data Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 23 sheets when we checked. The home must obtained appropriate information on each product in use in line with the COSHH requirements. Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 1 1 x x N/A 3 x x x x x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x 2 x x 3 Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP3 Regulation 14 (1)(2) Requirement People must only be admitted into the home if their needs match with the home’s category of registration and following a full needs assessment undertaken by a suitably qualified or trained person. This is to ensure the home can meet the persons needs. All incidents of safeguarding must be reported promptly to the local authority safeguarding of adults process. This is to ensure the safety and protection of people living at home. There should be sufficient numbers of staff on duty at all times to meet the needs of the people using the service. This is to ensure the health safety and welfare needs of people living at the home are met at all times. Timescale for action 25/09/08 2. OP18 13(6) 25/09/08 3. OP27 18(1)(a) 25/09/08 Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP1 OP2 Good Practice Recommendations The statement of purpose and service user guide must be reviewed. Contracts/terms and conditions of residence should be reviewed. This is to ensure that people know what to expect from the service and their/the service rights and obligations. The home needs to develop the assessment and care planning processes to show how it has consulted with people at the time of their admission to the home and on an ongoing basis. This is to ensure that people and/or their representatives are involved in the planning and review of care and are kept informed of any changes to care needs The complaints procedure should be reviewed to ensure people know how to complain and how their complaint will be dealt with. The manager attends protection of vulnerable adult for managers training. This is to ensure the manager is aware of how to deal with safeguarding issues. To review the role of domestic staff and contracted hours. An application to CSCI for registration should be made by the manager An effective quality assurance system should be developed to seek the views of people that use the service, their representatives and other interested stakeholders to ensure the service meets its stated aims and objectives. The financial handling of money and valuables policy should be reviewed. Care staff must be given supervision at least six times per year. This is to ensure they are supported and appropriately supervised to do their job. COSHH safety data sheets should be obtained for all products in use. 3. OP3 4. 5. 6. 7. 8. OP16 OP18 OP27 OP31 OP33 9. 10. 11. OP35 OP36 OP38 Lady Forester Residential & Day Care Centre DS0000020681.V372060.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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