Inspection on 14/06/06 for Lansdowne Road 75-77

This inspection was carried out on 14th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Lansdowne Road 75-77 09/10/08

Lansdowne Road 75-77 28/11/07

Lansdowne Road 75-77 02/11/06

Lansdowne Road 75-77 30/01/06

Lansdowne Road 75-77 13/07/05

Lansdowne Road 75-77 11/01/05

Lansdowne Road 75-77 13/07/04

Lansdowne Road 75-77 09/03/04

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

CARE HOMES FOR OLDER PEOPLE Lansdowne Road, 75-77 Handsworth Birmingham West Midlands B21 9AU Lead Inspector Sean Devine Unannounced Inspection 14th June 2006 09:00 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 Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 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. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lansdowne Road, 75-77 Address Handsworth Birmingham West Midlands B21 9AU 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) 0121 554 2738 F/P 0121 554 2738 Ms Delores Matadeen Vacant Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: 75-77 Lansdowne Road is situated in a popular residential area of Birmingham. It benefits from being close to local amenities including public transport, shops, health services and places of worship. The community is a rich mix of cultures, faiths and nationalities. The home was originally two houses. They have been thoughtfully converted into one large home. The home has three floors and there are residents bedrooms and bathrooms on all three levels. There are both single and shared rooms. No bedrooms have en-suite facilities. A passenger lift enables access to all floors. On the ground floor are a communal lounge and a large dining room. At the rear of the property is a pleasant garden and paved area. The home has a large kitchen. Main meal meals are prepared at another home in the company and delivered to the home. The home has a laundry and can undertake most routine washing of residents clothes and bedding. The home provides a service for older people with an enduring mental illness, nursing is not a service provided at the home. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two regulation inspectors conducted this key inspection over a period of one day. Prior to the visit the home was sent a pre-inspection questionnaire and requested to return it, the questionnaire was not received. The inspectors were able to meet with many of the residents, a relative and also a visiting health and social care professional. A tour of the home was undertaken including residents rooms, communal areas and staff work areas including the kitchen and laundry. Residents’ files’ including their care plans and other health and social care records were sampled as were staff files regarding training, recruitment and supervision. Records regarding the management of health and safety in the home were seen. It was evident that many residents do have needs around communication, which hindered gathering their views and opinions about the standards of care received by them at the home. The registered person was left the following immediate requirements at the end of the inspection: 1. A named resident must have care plans and risk assessments in place that instruct staff and reduce risks identified, copies must be forwarded to the commission by the 26/06/06. 2. Arrangements must be made to ensure all staff will receive safe working practice training, to be completed by 30/06/06. A copy of the training schedule must be forwarded to the commission by the 07/07/06. What the service does well: The staff do complete comprehensive and detailed assessments of need following admission. Residents are able to access all required healthcare services including their GP, district nurses, optician, dentists and chiropody. Two residents advised that they do see their doctor when they need to. They also commented that the staff will help them with personal care and with transport for hospital appointments. It was evident through observation that the staff do respect residents, residents clearly trusted the staff and the residents privacy and dignity was maintained at all times. A resident commented that the staff were nice and always helpful. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 6 Mealtimes are a social event, many residents have their meals in the dining room, although the menu is clearly displayed most residents were informed by staff what was on the menu and what the alternatives were. Several residents commented that the meal was nice. Some residents were given food supplements and others were assisted by staff to eat. Staff spoke with the residents and not exclusively with each other. The premises in all areas are well maintained. Residents’ rooms are very individual reflecting choices and personal memorabilia; two residents commented that they liked their rooms and enjoyed spending time there. All other areas of the home were clean and well organised. Residents are able to keep money in safekeeping. This is well managed and accessible for residents, one resident commented “staff give me my money when I ask them for it”. A relative commented that it helps that she knows her husband is well cared for and in safe hands. What has improved since the last inspection? What they could do better: All residents must have a care plan to inform staff about how they assist residents to meet their needs. The home does have a medicines policy, this must be revised to inform staff about how medicine is managed safely. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 7 It was evident that many residents were seated for much of the day, inspectors observed very little social activity although staff at all times appeared busy. The staff need to commence an activity programme that is individual to each resident that reflects their abilities and is purposeful in its practice. There were poor records to reflect staff training, the owner advised that many staff had received training, yet there was limited evidence of this on staff files and it is a concern that staff are not receiving induction training and training in safe working practices. The recruitment and selection practices are poor to adequately protect residents including the gathering of references, completing criminal bureau disclosures and checking the protection of vulnerable adults register. Improvements are needed to ensure these processes are robust and protect the residents. As identified at previous inspections it is imperative that the home recruits an experienced and competent care manager as this post has been vacant for several years. This will help improve the day to day operations of the home and improve the services received by the residents. 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. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 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 Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 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 the following standard(s): Standards 3 and 6. The quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the home. The home has the ability and capacity to ensure that they can meet the needs of residents prior to agreeing permanent residency. EVIDENCE: There have been no recent admissions to the home. Two residents’ files were sampled, one for a long-term resident and another for a resident living at the home for six months. The second file included details of a case conference on this resident detailing previous behaviour and also presenting illness on and prior to admission. It was evident that the assessment of need for the longer term resident was overdue a review, the form for review was available however it had not been completed. The home does not provide a service for intermediate care. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10. The quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the home. The home does not demonstrate its capacity to plan effective care in consultation with residents and their representatives, which may lead to residents receiving inappropriate care. Residents are treated with respect, they are able to access healthcare services and their medicines are managed safely. EVIDENCE: The sampled residents files both included detailed assessments of need for all activities of daily living, these assessments had been used to then develop care plans and risk assessments for the long term resident. The care plans for the long-term resident were instructive to staff, although many were repetitive and they often went on to repeat the assessment. It was clear that they require updating to reflect present care needs for example this resident now needs to use a wheelchair at times, this was not included in the care plan for mobility. Care plans were reviewed on a monthly basis. The reviews were informative Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 11 and reflected on how effective the plan had been. There was no evidence to indicate that the resident or a representative had been involved within the care planning process. The second residents file did not contain any care plans it included a mental health assessment, which identified risks and needs. No risk assessments or associated management plans were available. The registered person was left an immediate requirement to ensure this resident has care plan and risk assessments in place to instruct staff and to reduce risk. Risk assessments including personal, moving and handling, falls and nutritional screening were completed for the long term resident, no tissue viability screening was evident. The falls risk assessment did not adequately instruct staff in what to do in the event of a fall. Both residents files recorded appointments and visits from community healthcare professionals including GP, district nurse, optician, dentist and chiropodist. A social worker visited the home on the day of the inspection, her feedback was positive about the home and she had no concerns. A weight monitoring chart was available for one resident, although there were no concerns at present this resident had only been weighed once in six months, which is not adequate for early identification of concern. Both residents require that the home manage their medicines. A local GP prescribes and they are dispensed by a community chemist, mainly in weekly cassettes, however some medicines are bottled or boxed and are supplied for 28 days. There was evidence that some medicines when received are not signed for or recorded as received and some stock of medicines were found to be inaccurate. All administrations of medicine to residents were signed for. Staff explained that they have been registered with a college to undertake an accredited course in the safe handling of medicines. Copies of the GP prescriptions are taken for each resident, these are used to ensure that the correct medicines are received into the home. The medicines policy was seen and this describes the processes involved from ordering medicines through to returning medicines to the chemist. The policy needs to describe all current practices including the use of cassettes. The personal care needs for one resident includes care plans which, describe to staff that they must deliver care with respect, dignity and in privacy. Staff were observed, at all times they were seen to maintain the dignity and privacy of the residents, including tone of speech, awareness of surroundings and knowledge of residents choice. At the inspection one resident remarked “its ideal for me here, much better than being in hospital” and another stated “my socks are odd and they are too tight”, the second remark being heard by staff and quickly addressed. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 12 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 the following standard(s): Standards 12, 13, 14 and 15. The quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the home. The ability of the home to at all times provide an individual approach to the daily lives and social activity of residents is not evident, this may put residents at risk of receiving inappropriate care and does not altogether promote their personal choices. EVIDENCE: The lifestyle needs for one resident were assessed and planned for including hobbies, social and cultural needs. However the other sampled file did not contain such assessments and care plans. Daily records for two residents were sparse in respect of any organised activity internal and external to the home; it is evident that more relaxed activity for e.g. conversation, reading papers, nail care etc are not always recorded. One resident stated he enjoys the exercise group on a Monday, and that it helped with staying fit, he also stated he enjoyed it, as it was fun and there was some music and songs he liked. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 13 One resident commented that his wife does visit regularly, although not as often as he wished. On the day of inspection the relative of a resident stated she feels the home is okay, and how important it was to have a place at the home to ensure that the resident is cared for and kept active. The financial affairs of all residents are either managed by the home or by a relative. Due to significant loss of ability related to their physical and mental health all residents are unable to manage these affairs. It is evident in some residents’ rooms that they have been able to bring personal possessions into the home including small items of furniture, photos and memorabilia. As recorded it is not evident that all residents are able to make choices when needs are assessed and care plans and risk assessments devised, their views and opinions are not sought when care plans are reviewed. Most residents have an assessment of their needs completed, including food and mealtimes and also a nutritional screening assessment, if there is a need or a risk either a care plan or risk assessment is developed and implemented. One inspector sampled a meal, previously meals have been cooked and transferred to the home from the close by 9 Radnor Rd, which is part of the Lyndel Homes group, this is no longer regular practice except on Sundays. The meal was found to be a good portion, tasty and well presented. Most residents have their meals in the dining area, the menu does have alternatives and the menu is displayed on the notice board. Many residents are unable to see and read the menu so the staff speak with residents asking for their choices. One resident described the meal as being “very good” another said “I like lunchtime best”. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 14 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 the following standard(s): Standard 16 and 18 The quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the home. The capacity for the home to listen and respond to complaints of residents and their representatives is effective, however the ability to take measures to protect residents from abuse is not and this may condone abusive practices. EVIDENCE: The home has policies for complaints and also for the protection of vulnerable adults from abuse. The complaints policy is well written and provides good guidance for staff. The protection of vulnerable adults from abuse policy needs improvement to ensure that all abuse and suspected abuse is reported to the social services and also to the commission as a matter of practice and not just a possibility. A complaints form is available on the large notice board in the dining room. When these forms are received they are moved into the complaints log, there have been no complaints since the last inspection either at the home or received at the commission. Several residents informed the inspectors that they have no concerns or complaints regarding the service and quality of care at the home. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 15 The training records seen by the inspector did not include training staff to protect residents from abuse, several staff confirmed that they had not received this training. It was evident in discussions with staff that if they do have concerns about suspected abuse that they would always refer to the appropriate agencies. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 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 the following standard(s): Standards 19, 20, 21, 22, 23, 24 and 26. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The environment for both individual and groups of residents is able to meet their needs, facilities, space and hygiene are good to promote well being and safety. EVIDENCE: There has been recent improvement to the home including replacement floor in the lounge, some chairs have been replaced and the registered person indicated that new armchairs of varying styles are in the process of being ordered. New work surfaces have been fitted in the kitchen and there has also been minor repair to the lounge wall where wheelchairs had caused damage. As requested at previous inspections the registered person must provide the commission with a programme of routine maintenance and renewal for the fabric and decoration of the home. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 17 There is one large lounge area, a dining area and a fairly flat rear garden all are well maintained (steps up to lawn area from patio), residents often use the garden to smoke or if the weather is poor the dining area when food is not being eaten. There are toilets and washing facilities on all floors (ground, first and second floors), all toilets have good hand washing facilities and are close by residents’ rooms. On the first floor there is a well maintained shower and medi-bath and on the second floor there is an assisted bathroom. The passenger lift provides access to all floors, hallways have hand rails and bathrooms and shower rooms and toilet areas have grab rails where needed to provide support for residents with mobility needs. Residents’ rooms are on all floors, some are shared and some are single rooms. The room sizes are large and spacious and provide adequate furniture and fittings for the residents. However one shared room did not have a privacy screen to maintain dignity and privacy of both residents. The fabrics and bedding were seen to be of good quality and some rooms contained many personal items. Two residents informed the inspector that they liked their rooms and one resident who shares a room enjoyed the company, although he said he did not talk very often to the other resident. Residents’ rooms and all communal areas were found to be clean and free from offensive odours. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. The quality in this outcome adequate is poor. This judgement has been made using available evidence including a visit to the home. There are good numbers of staff on duty, however the homes ability to train staff and protect residents through robust recruitment and selection practices may lead to residents needs not being effectively met and their well being put at risk. EVIDENCE: Residents informed the inspectors that there are always staff on duty who are available to help and give them support when needed. This was further supported by the staff duty roster, however it was not always clear who was on duty and what role they were performing as recent changes due to staff sickness had not been made on the roster. The home was sent a pre inspection questionnaire this was not returned to the commission by the home prior to or following inspection, thus details regarding how many staff have achieved or are studying NVQ level 2 in Care were not made available. Two staff files were sampled; the registered person informed the inspectors that the recruitment details for one member of staff were at another home in the Lyndel organisation. For this member of staff there was an application Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 19 form, there were no written references or Criminal Records Bureau disclosure (CRB) on the file. The second member of staff had a fully completed application form and two written references, however the CRB had not been completed by the home, it had been completed by a previous employer. One of the two staff files included a health screening and one file had a recent photograph of the member of staff. The staff files seen contained little information about training, one file had a recent First Aid certificate and evidence that an Induction to Work in Social Care had been completed, there were also other training certificates including challenging behaviour and caring for people affected by strokes, there was no evidence that current training in safe working practices had been undertaken. On the second file there was evidence of health and safety training, no other training had been recorded. The registered person provided a list of training for all staff at Lansdowne Rd, there were no records that the second member of staff had completed any training in safe working practices or undertaken a Skills for Care induction. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 and 38. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The capacity for the management and administration of the home to ensure effective operations in meeting the needs of residents’ remains a concern, without an experienced and knowledgeable care manager residents may have their health and welfare put at risk. EVIDENCE: The home remains without a care manager. The registered person advised of her efforts to employ a care manager providing evidence through adverts and correspondence with employment agencies and with the job centre. Some applications had been received and the registered person is at present arranging interviews. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 21 The registered person advised inspectors that consultation with staff, residents, relatives and visiting professional had commenced, that she was at present at the stage of gathering the information in order to prepare a report about quality assurance. The home does manage money on behalf of some of the residents; it was evident that this is well managed, transparent and accurate. Balances and accounts are reconciled and receipts are available for expenditure made by the staff on behalf of residents. One resident stated he has enough money and that if he needs it he can get it from the staff. Accounts are regularly checked and there is a full audit by an accountant every six months. The two staff files did not contain any information about regular supervision, the registered person advised that these documents were not available as they are in the process of being audited. Policies and procedures were sampled including, complaints, adult protection, accidents, gender and intimate care and guardianship. The complaints policy and adult protection policy have been reported upon in the Complaints and Protection area of this report. The three other polices are well written and provide staff with clear guidance as to what actions are needed. The home has a well maintained, tested and serviced fire system, this is further supported by a detailed fire risk assessment. The system used requires that evidence of findings and compliance be conducted, this had not been completed. Staff are attending fire drills, however the registered person needs to ensure that all staff attend at least two drills annually; the registered person advised that this will be achieved. As reported upon in the Staffing area of this report, it is not evident that all staff receive training in all safe working practices; this includes annual fire safety training. Risk assessments for the premises, staff and food are available, the food risk assessment requires updating to fully reflect on current practices and all other risk assessments are reviewed annually. There were risk assessments in place to ensure the safety of residents and staff whilst the new flooring was laid. Other health and safety tests, maintenance and servicing is completed including the passenger lift, hoists and gas and electrical safety. Residents and visitors to the home had no concerns in respect of their safety. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 3 2 X 3 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 2 2 2 Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes. 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(2)(a) Requirement All residents’ assessments of need must be subject to regular review. Previous timescale of 30/9/05 not met, this requirement is carried forward. Written care plans must be in place to instruct staff in how to meet all residents’ needs. Previous timescale of 31/08/05 not met, this requirement is carried forward. 3 OP7 15(1) 13(4) 12(1) Residents must have care plans and risk assessments in place to instruct staff and reduce risks, copies for one named resident must be forwarded to the commission by the 26/06/06. Fall risk assessments must have the associated management plan include details of what staff must do should the resident fall. All residents must have a tissue viability screening completed, where risks are prevalent a risk Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 24 Timescale for action 31/08/06 2 OP7 15(1) 31/07/06 26/06/06 4 OP8 15(1) 13(4) 31/07/06 5 OP8 12(1) 13(4) 13(2) 6 OP9 management plan must be introduced. Residents’ weights must be monitored regularly to ensure that any concerns are identified at an early stage. All medicines when received into the home must be checked, including who received the medicine, when it was received and the amount received. Audits of stocks of medicines must be completed accurately and outcomes must be recorded. The medicines policy must be reviewed and updated to reflect and describe all current practice, e.g. use of cassettes. Care plans including social activity, family involvement and lifestyle must be completed and a programme of activity to reflect these choices implemented. The adult protection policy must be revised to include details of reporting all alleged abuse to the social services and the commission. All staff must receive training in how to protect vulnerable adults from abuse. A programme of routine maintenance and renewal for the fabric and decoration needs to be produced and implemented. Previous timescale of 30/04/06 not completed, this requirement is carried forward. Privacy curtains must be available and used in all shared rooms. The staff roster must include who is on duty for each shift, the hours they work and in what DS0000016836.V290511.R01.S.doc 31/07/06 31/08/06 7 OP9 13(2) 30/09/06 8 OP12 16(2)(m)( n) 31/08/06 9 OP18 13(6) 30/09/06 10 OP19 23(1)(2) 30/09/06 11 12 OP24 OP27 16(2)(c) 17(2) sch 4(7) 31/07/06 31/07/06 Lansdowne Road, 75-77 Version 5.1 Page 25 13 OP28 18(1)(c)(i ) 14 OP29 19(1)(b)2 capacity. The registered person must ensure that as a minimum 50 of the care workforce are qualified to at least NVQ level 2 in Care. All staff must have a recent photograph upon their file. As part of the recruitment practice a health screening assessment must be completed for all staff. Previous requirement of 31/03/06 not met, this requirement is carried forward. All new employees must have a Criminal Records Bureau disclosure and POVA check completed prior to employment. New employees may commence duty under supervision if the POVA check was negative and has been received at the home whilst awaiting CRB. All new employees must have two written references prior to employment and these must be available for inspection in the home. Certified evidence that training has been completed must be maintained where possible. Previous timescale of 31/03/06 not met, this requirement is carried forward. Arrangements must be made to ensure all staff will receive safe working practice training, to be completed by 30/06/06. A copy of the training schedule must be forwarded to the commission by the 7/7/07 Staff training specific to the residents needs must be DS0000016836.V290511.R01.S.doc 31/10/06 31/07/06 15 OP29 19(1)(a)( b)(c) sch 2. 17(2) sch 4(f) 31/07/06 16 OP30 18(1)(c)(i ) 30/09/06 17 OP30 18(1)(c)(i ) 07/07/06 18 OP30 18(1 c)(i) 31/10/06 Page 26 Lansdowne Road, 75-77 Version 5.1 undertaken and include: 1) Mental Health Awareness. Previous timescale of 31/03/06 not met, this requirement is carried forward. 19 OP31 8(1)(a) A suitably qualified, competent manager must be recruited. They must be experienced in care of service users with mental ill health. This must be addressed as a matter of urgency and the provider must advise of arrangements being made to recruit another manager and the date when an appointment is expected to be made. Details of the managers experience, competencies and qualifications must be included within the statement of purpose and service users guide. Previous timescale of 30/6/05 not met, this requirement is carried forward as a matter of urgency. An annual report of Quality Assurance review must be available to residents and forwarded to the commission. All care staff must receive ongoing regular supervision at a frequency that provides them with adequate support. The fire risk assessment when reviewed must detail the findings and areas of compliance. All staff must receive annual fire safety training. The risk assessment related to food safety must be updated and reflect current practices, DS0000016836.V290511.R01.S.doc 31/08/06 20 OP33 24 30/09/06 21 OP36 18(2) 31/08/06 22 23 24 OP38 OP38 OP38 23(4) 23(4)(4)( d) 13(4)(c) 30/09/06 31/10/06 31/07/06 Lansdowne Road, 75-77 Version 5.1 Page 27 including details that the Sunday meal is prepared and cooked at 9 Radnor Rd and how safety is at all times maintained. 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 OP14 Good Practice Recommendations The registered person should look at other methods to inform residents of how they can be supported by external agencies, for example the need for advocacy. Not assessed at this inspection and is carried forward. Lansdowne Road, 75-77 DS0000016836.V290511.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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