Inspection on 02/11/06 for Lansdowne Road 75-77

This inspection was carried out on 2nd November 2006.

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

Lansdowne Road 75-77 09/10/08

Lansdowne Road 75-77 28/11/07

Lansdowne Road 75-77 14/06/06

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 2nd November 2006 09:30 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.V314812.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. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 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.V314812.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 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. During the inspection the registered person advised that the scale of current charges for the home range from £328.00 to £398.00 each week. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was undertaken over one day (8.5 hours) and was unannounced by one regulation inspector. The inspector was able to meet and talk with most of the residents, many of the staff and the owner. Many of the residents have a degree of cognitive impairment, which does affect their ability to communicate and therefore their views and opinions of the service are at times unclear. Records about the social and health care of residents were seen including care plans and medication, and staff informally discussed their practices. Health and safety records, tests and servicing were sampled and a tour of the communal areas of the home was completed. Records about complaints were seen, there have been no complaints to the home by concerned residents or their representatives and the Commission has not received any in the past twelve months. At the end of the inspection urgent issues to feedback to the owner included the lack of care planning and implementation for one resident who had lost a lot of weight and as at many previous inspections the owner has yet to appoint a care manager. Prior to the inspection an inspection questionnaire and resident survey letters (known as “have your say about…”) were sent to the home. The questionnaire was not completed or returned and six residents returned the survey letters out of thirteen. What the service does well: The home has devised a general programme of activity in the home, which is full implemented and does keep some of the residents busy and occupied. Residents indicated that they enjoy these activities and instigated some activities such as playing the organ and singing themselves. Staff are available in good numbers at busy times of the day, which ensures residents do not have to wait long before assistance and support can be given. Residents stated and advised in the survey that staff treat them well, that they do not have any concerns and that they feel safe. The maintenance in respect of health and safety is good, the building is risk assessed; utilities and equipment are maintained, tested and serviced where needed. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There are twenty-nine requirements to improve this service made as of this inspection. Eight of those carried forward from the last inspection. The most serious are the ones that have a direct and immediate impact on the physical health of residents, they include ensuring all residents have a good fluid intake and healthy nutritional meals are provided regularly each day. Staff were seen to be caring and supportive of residents, yet they do not have any training to develop an understanding of mental ill health and how this will effect the health and abilities of residents. Residents are provided with a lunchtime meal that is prepared, cooked and transported to the home from another home in the Lyndel Organisation. Residents did not have a menu and it is not apparent how their likes and dislikes, culture and lifestyle needs are met this may cause them considerable emotional distress, effect their dietary intake and negotiate their beliefs; the staff on duty were aware of which residents require a blended and diabetic meal. There are risk assessment pertaining to fire and food safety that require updating as they have either not been adequately reviewed or do not describe Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 7 current practices and adequate safety measures to reduce the risk to residents and other people. The owner agreed that much of the decisions taken at the home are reactive and are not often thought out and planned. Many of the areas of poor and adequate performance are due to the home not having a competent, skilled and qualified Care Manager. This has had a direct impact on the standards of service and care delivery, which is not good enough to meet the needs, strengths and beliefs of 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.V314812.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 Lansdowne Road, 75-77 DS0000016836.V314812.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 and 3. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has not been able to demonstrate it has the full capacity to assess the needs of residents which will in turn enable them to plan with the resident the care they require, this may lead to residents receiving inappropriate care which will be detrimental to their physical and mental health. EVIDENCE: The two residents whose files were case tracked did have a contract about their terms and conditions of residency, one of the contracts had not been signed by the resident or a representative and neither recorded current fees to be paid and the room number to be occupied. All residents who returned the survey confirmed that they had received a contract. Both residents files contained some pre admission assessments completed by the referring social workers, this was in the form of a care plan. The inspector was informed of a new admission to the home. Pre admission assessments Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 10 were not available for this resident, the owner advised that she has an assessment by a psychiatrist but it was not at the home. All residents who returned the survey confirmed that they received enough information about the home before they moved in. One resident who said he had been at the home for three months said “It’s a good home, I like it and I came to visit”. Lansdowne Road, 75-77 DS0000016836.V314812.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 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 area is poor. This judgement has been made using available evidence and a visit to the home. The home has not demonstrated it has the ability to meet the health and personal care needs of the residents, it is a concern that where changes in health have been identified care has not been revised and this puts the health of residents at increased risk possible endangering life. EVIDENCE: Two residents had very detailed assessments completed about many areas of their lives, it included most activities of daily living and not only described the needs of residents but also some of their abilities, likes, choices and preferences. They had also been updated to reflect the changing needs of residents. For one resident some assessments had been updated following a fall, including falls risk assessment, mobility care plan and an evacuation (fire) risk assessment. This resident had recently lost a lot of weight and the home had consulted the doctor and dietician, however no immediate care plans had been developed and implemented to increase weight, whilst the advice was sought to try and improve the health of this resident. There was a nutritional Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 12 screening available, this was not reviewed following weight loss and it was evident at mealtimes that the nutritional needs of this resident had not catered for; the owner advised of food supplements, none were given and none had been prescribed by the doctor. Most other care plans were well written, clear and concise detailing actions staff must take, however for one resident the social activity care plan did not describe any preferences of pastimes, current hobbies or aspirations even though some had been identified in the assessment. Both residents have assessments and risks assessments for moving and handling, skin condition, falls and nutrition; it was evident that some of these were reviewed after significant incidents. The staff at the home do record the diet and fluid intake of each resident, for two residents the fluid intake is either very low or records are not adequately maintained, this was discussed with the owner who advised that they are not being fully completed. For one resident the skin condition risk assessment indicated very high risk but it was unclear from the risk assessment why this was. Residents were seen to have frequent drinks of tea, yet this is not in excess of 1.5 litres a day and may contribute to a state of dehydration. The weights for both these residents are monitored but this is not completed regularly. Residents indicated in the survey that they were happy with how staff treated them. Health records maintained by the home indicate that residents are well supported to access all required community healthcare services including doctors and community nurses, dentists, opticians, chiropody and hospital appointments. The majority of residents in the survey indicated that they receive medical support when they require it. Many residents do require assistance with personal care, for the majority of the time this was conducted with respect and dignity, however on one occasion a resident was “told off” for being impatient. Residents indicated in the survey that staff listen to them and act upon what they say. The staff at the home have been trained in the management of residents medicines. Medicines are prescribed by the residents’ doctor and dispensed in weekly cassettes to the home by a community chemist. The management of medicines for two residents was audited. It was evident that the system is safe with good record keeping and accurate stocks of medicines, all medication could be accounted for whether administered to the resident or returned to the chemist. The medicines policy for the home has been reviewed to include the current practices, and copies of doctors’ prescriptions are made to help check accuracy when medicines are received at the home. Improvements are needed in the following areas, the container used to store medicines in the fridge must be lockable, however a separate medicines fridge is needed and preparations such as eye drops must be disposed of after opening within the time specified on the packaging. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 13 Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 14 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 area is adequate. This judgement has been made using available evidence and a visit to the home. The home has not demonstrated it has the full ability to meet the daily life and social activity needs of all residents. The home has implemented some much needed activity in the home, this needs to be improved upon and individual needs met. The mealtimes are not always nutritional good for some residents and this may put their health at risk. EVIDENCE: The residents’ files contained some information about their lifestyles, personal history and social activity within assessments. This information needs to be included within the individual residents care plans to guide staff in how to meet the needs and maintain abilities that were identified. There is a general activity plan that many of the residents who spend most of their time in the home participate in; this was structured and on the day of inspection adhered to; this included a visit from local church members for prayers and hymns, ball games and exercise and board games. One resident started playing the homes organ and many residents joined in a sing along, which they all seemed to enjoy. The general activity planner also includes activities such as relaxation, arts and crafts and for some resident’s trips out. For one resident who is fully mobile but can only safely manage shorter journeys the staff have Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 15 made available a wheelchair for outing and trips. Residents commented that they enjoyed the activities in the home and all the residents who returned the survey indicated that there were activities in the home that they can take part in. As recorded above, visitors from the local community are involved with activities in the home, this is very positive and many residents were seen in discussion with these visitors. Two residents informed the inspector that they have regular visits from members of their family and another resident said he has regular phone calls from his wife. Care plans about maintaining family involvement were available for residents describing for example, help with reading letters and when to expect phone calls and a separate record of visits by family is maintained for residents. There is a monthly key worker report that often refers to family involvement, visits and other correspondence during that month. Residents’ files contained a care plan agreement; residents had signed them to agree with the care and support to be given. The residents had care plans about the support they need to manage their finances and who is involved to support them. There were care plans about, personal care, religious observance and food and mealtimes, however how residents make choices such as the style of dress they like and if they wear make up had not been recorded and there were no care plans to guide staff in how to support this. The inspector arrived shortly after breakfast had finished, however one resident who was going out said “I’ve had my breakfast and I’m going out now”, one resident was seen finishing a bowl of cereals. At 10am snacks and refreshments were served, including hot drinks, toast, fruit and biscuits. Staff were aware of the residents who required softer food and provided it. Lunch was served at 12.30pm and lasted approximately one hour. A menu of the days meals was not available. Residents were served a choice of hot meals, being sausage, potatoes and mixed vegetables or corn beef, potatoes and mixed vegetables. Meal sizes were of good portions and the food sampled by the inspector palatable. At present lunchtime food is prepared and cooked at another care home 9 Radnor Rd, which is close by and transferred when cooked to the home in thermostatic containers. It is not clear how the residents at 75-77 Lansdowne Road influence the menu and how their choices are included, some residents commented “the food is nice”, another resident commented “I don’t get West Indian food”, on checking the daily choice of menu, it was apparent this resident is provided with such a meal but not on a daily basis. The lunch meal was a sociable occasion; many residents were talking to one another and staff. Two residents required more support from staff to eat their meal and staff did this with sensitivity and care. Two residents who were not at the home for lunch have arrangements in place, one has it at a day centre and another has it kept for his return and takes out a packed lunch. The dining room is also used as a designated smoking area when mealtimes are over, there was concern that when staff were busy some Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 16 residents would go outside for a cigarette or a walk and leave the dining room door open; the dining room quickly became very cold and uncomfortable for some residents. No dessert was offered to residents, the inspector enquired why? The senior care on duty advised that dessert is often served with the tea, shortly after this discussion some residents were served jelly, fruit and one had some biscuits. This was discussed with the owner as the lunchtime could be used for some residents to have high energy / carbohydrate puddings to help improve body weight. The owner was positive about this and intends to revisit the menu after consulting the dietician and residents. The residents had a further snack and hot drinks at 3pm and the tea, which was assorted cold sandwiches, was being served at 5.30pm. Stocks of food for the residents were seen to be low, the owner advised that the following day food is due to be delivered by a supermarket delivery service. Some food items in the freezer had not been dated and the owner was unable to locate the most recent environmental health report. The owner advised that the actions required had been completed and would forward a copy of the report and subsequent actions to the Commission. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home does demonstrate it has the resources and processes to effectively manage complaints and protect residents, however staff require further guidance to raise their concerns and improve the service to residents. EVIDENCE: Residents who returned the survey had no complaints to make and other residents who spoke with the inspector did not have any complaints. The complaints policy is advertised on the notice board in the dining room and included with each residents guide and also within his or her contract. The home does maintain a log of complaints; those seen for the year 2006 did not refer to complaints made by residents or their representatives but had been made by staff following concerns about the challenging behaviours of some residents. The was discussed with the owner as other policies and procedures should be followed by staff to raise their concerns such as supervision and managing untoward incidents. No complaints have been received at the Commission about the home in the past twelve months. Staff training records indicate that all staff have received recent training about the protection of vulnerable adults. The policy for managing suspicion of or evidence of abuse has not altered and is satisfactory to protect the residents who live at the home. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 18 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 19,21 and 26. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has some ability to meet the communal environment needs of residents, however in some areas the décor and infection control practices need to be improved to ensure it does not put the health and safety of residents and staff at risk. EVIDENCE: Resident surveys indicated that the home was always kept fresh and clean. This was further confirmed when the inspector viewed all communal areas including toilets and bathrooms. The dining room, lounge and garden are in constant use by residents at the home and all are generally well maintained, with all fixtures and fittings fit for purpose. Some redecoration is needed in the dining area to paintwork. There is a range of toilets and bathing facilities available on all three floors of the home close to residents’ rooms. The facilities are varied including seated Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 19 baths and showers some with a hoist facility. The hoist used as a seat in the ground floor shower room requires arms to ensure safety and the lock on the door of the seated bath on the first floor requires fixing so it can fully close. All toilets and bathrooms had good hand washing facilities and some had receptacles for disposing of waste including sanitary and clinical. The laundry room is small and has a washing machine with a sluice cycle and a tumble dryer, residents and staff have some facilities to practice good infection control such as soiled items of laundry, including net bags, hard impermeable flooring and a wash hand basin, however there were no soap or paper towels in the laundry. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 20 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): All standards. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it does have the ability to provide the residents with staff who are trained, safely recruited and available in numbers to meet their needs. However there are some gaps including staff training and this may leave the residents open to poor or inappropriate care. EVIDENCE: The residents survey indicated that they are treated well by the staff. Many staff were observed supporting residents and on most occasions care, support and advice was given with skill and respect. The staffing rota indicates that adequate numbers of staff are at work at busy times to support the needs of residents, at present some staff are working additional and split shifts to cover some annual leave and sickness absence. Therefore staffing rotas are changing on a daily basis where needed. On the day of inspection the owner updated the rota to include, which staff were on the afternoon shift. During busy periods of the day there are a minimum of three senior care assistants or care assistants on duty and a part time housekeeper to support the thirteen residents. At night there are two waking care assistants on duty. The owner advised that all but one member of the staff had completed the NVQ level 2 awards or above and that this member of staff has commenced the course. Some staff have achieved the NVQ level 3 and level 4 awards. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 21 This means that in excess of 90 of the staff team have achieved the nationally accredited awards. There have been no new appointments to the home since the last inspection so no staff have commenced induction based upon the Skills for Care units and elements. At the last inspection one member of staff did not have evidence that a Criminal Records Bureau disclosure (CRB) and POVA register check had been completed, prior to offering employment. Evidence these had been completed were not available at the home; the owner advised that these had been completed; the inspector advised that the POVA register check be forwarded to the Commission; with the CRB being checked at the next inspection of the home. It was evident from the staff training matrix that all staff are receiving training in many safe working practices including fire safety, health and safety, and infection control, however this is not comprehensive and further training is needed for basic food hygiene and moving and handling. The owner advised that she is undertaking training, which will enable her to train the staff in moving and handling. With regard to training about the specific needs of residents many staff have undertaken training about Dementia Care; however there were no records that indicate staff have completed training in Mental Health Awareness. Other staff had undertaken training since the training matrix was originally completed, the owner indicated she would update these records and forward a copy to the Commission. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 22 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 and 38. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home does not demonstrate it is effectively managed and well planned administration is not fully considered with the management being reactive by the owner, this has a negative impact on residents. Residents and their representative’s views and opinions are being considered; this will help focus some areas of improvements from the residents’ point of view. EVIDENCE: The owner advised the inspector of her continued efforts to recruit a suitable experienced and qualified Care Manager. She advised that she would be interviewing some prospective candidates very shortly with a view to offering a post on a three month trial period. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 23 The owner provided some questionnaires recently completed by many of the home residents and their relatives about the quality of life and care at the home. She advised she was in the process of collating the information and would in turn provide a quality report based upon the information gathered. She hopes to include where the home does well and where improvements are needed. The home does provide a safekeeping service for many of the residents at the home to support them with managing their money. As previously identified residents do have a care plan that described why they need this service. The records seen included where money had come into the account and when it had gone out. Two staff had signed all transactions; this is inappropriate for one resident who would be able to sign for the transaction. The current balance and money available in two accounts were seen to be accurate and receipts were available where the home had made payment for a service such as hairdressing or for toiletries on behalf of the residents. Some residents continue to pay for taxis so they can attend medical appointments, the owner advised of some of the reasons why, such as one resident does not like sharing transport and one likes to use the wheelchair. This was not evident in an assessment and it was not seen to be recorded on any other records, it is not clear it is the choice of the resident. The home does have a fire risk assessment this was last reviewed on the 10th March 2006, it says “no change” it does not demonstrate that compliance checks against the stated measures to reduce risks are made and that these findings are recorded. It does not record that the fire officer has since visited and made requirements of the home to improve evacuation. However the owner did show the inspector how she had complied with the fire officers requirements including fitting a front door override switch. Fire tests and servicing of equipment including fire drills are routinely completed and each resident has an evacuation plan, these were seen to require updating as some residents have moved rooms. The owner provided evidence of furthers tests and servicing of gas, electric, emergency call, lift, water and hoists and wheelchairs. There are many health and safety risk assessments to cover the premises, staff and use of equipment with most being reviewed on a six monthly basis. At the last inspection a food risk assessment, detailing how food safety is maintained when food is transported from 9 Radnor Rd was required; this had not been completed. The COSHH cupboard in the laundry was found to be open, this was locked by the owner at the time of inspection. It was of concern that a resident who had suffered a fall in the home and had sustained serious injuries had not had an accident form completed, staff Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 24 advised that this had been completed but they could not find it. The Commission were informed by the home via a Regulation 37 notification of this accident. Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 25 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 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 X X X 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 1 X 2 X 2 2 X 2 Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 26 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 OP2 Regulation 5(1)(b) Requirement Timescale for action 31/12/06 2 OP3 14(1) The registered person must ensure that all residents have a contract that reflects current fees and accommodation including the room they occupy The registered person must 30/11/06 ensure that all residents’ needs, have been assessed by a suitable qualified and or trained person, that the resident or their representative is involved in the assessment. The registered person must have a copy of this assessment and must confirm in writing to the resident whether they can provide a suitable service. The registered person must ensure that as advised at the inspection that health care plans relating to weight gain and nutrition are fully implemented for one named resident, this can be revised when further information is available from the doctor and dietician. The registered person must ensure that all relevant DS0000016836.V314812.R01.S.doc 3 OP7 12(1) 10/11/06 4 OP7 14(2)(a) 15(2)(b) 10/11/06 Lansdowne Road, 75-77 Version 5.2 Page 27 5 OP8 15(1)13(4 ) assessments of needs and care plans are reviewed and updated following significant incidents. All residents must have a skin condition assessments completed, where risks are prevalent a risk management plan must be introduced. 30/11/06 6 OP8 12(1)13(4 ) Previous timescale of 31/07/06 not completed, this requirement is carried forward. Residents’ weights must be 30/11/06 monitored regularly to ensure that any concerns are identified at an early stage. Previous timescale of 31/07/06 not completed, this requirement is carried forward. The registered person must 10/11/06 ensure that all residents do have adequate amounts of fluid intake and are not at risk through lack of fluid intake of dehydration. The registered person must 10/11/06 ensure that all medication including medicines that refrigeration are safely stored. The registered person must ensure that all medicines are disposed when opened within the time specified on the packaging. The registered person must 10/11/06 ensure that at all times residents are treated with dignity and respect. 31/12/06 Care plans including social activity and lifestyle must be completed and a programme of activity to reflect these choices implemented. Previous timescale of 31/08/06 not completed, this 7 OP8 12(1) 13(4)(c) 8 OP9 13(2) 9 OP10 12(4)(a) 10 OP12 OP7 16(2)(m)( n) Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 28 11 OP14 OP7 12(2)(3)( 4(b) 12 OP15 12(1)(2)( 3)(4)(b) 16(2)(i) requirement is carried forward. The registered person must 31/12/06 ensure that the residents are able to make choices that reflect their background and culture and promote autonomy; including for example what they wear and how they dress. Care plans must be in place to inform staff of these choices. The registered person must 30/11/06 ensure that all residents can have a choice of the food they eat, that a menu is available for them to choose including alternative meals. The registered person must consult residents about what meals they want on their menu and consider individual backgrounds, likes and dislikes and healthy options. The registered person must ensure that the dining room is kept warm and comfortable for residents to enjoy their meals. The registered person must ensure that all food stored in the refrigerator is dated and checked for safety. The registered person must forward a copy of their last EHO report and subsequent actions to the Commission. The registered person must ensure that the complaints log is appropriately completed as required in the home complaints policy. The registered person must ensure that the dining area where required is redecorated. The registered person must ensure that all equipment used in the home is safe, including DS0000016836.V314812.R01.S.doc 13 OP15 23(2)(p) 12(1)(a) 12(1) 13(4)(c) 16(2)(j) 10/11/06 14 OP15 OP38 10/11/06 15 OP16 22(8) 30/11/06 16 17 OP19 OP21 23(2)(d) 23(2)(c) 13(4) 31/12/06 30/11/06 Lansdowne Road, 75-77 Version 5.2 Page 29 18 OP26 13(4)(c) 13(3) 19(1)(a)( b)(c) sch 2.17(2) sch 4(f) 18(1 c)(i) 19 OP29 providing arms for the hoist in the shower room and that the lock on the seated bath is repaired. The registered person must ensure that the laundry at all times had good hand washing facilities. The POVA register check for one named member of staff must be sent to the commission. Staff training specific to the residents needs must be undertaken and include: 1) Mental Health Awareness. Previous timescale of 31/03/06 not met, this requirement is carried forward. All staff must receive training in moving and handling and basic food hygiene. A suitably qualified, competent manager must be recruited. They must be experienced in care of service users with mental health needs. 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 10/11/06 30/11/06 20 OP30 31/01/07 21 OP31 8(1)(a) 30/11/06 Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 30 requirement is carried forward as a matter of urgency. 22 OP33 24 An annual report of Quality Assurance review must be available to residents and forwarded to the commission. 31/12/06 23 OP35 13(4)(c)( 6) 16(2)(i) 24 OP35 13(4)(6) 13(1)(b) 25 OP36 18(2) Previous timescale of 30/09/06 not completed, this requirement is carried forward. The registered person must 10/11/06 ensure that residents who are able to sign for their money when it comes in and out of their account at the home are supported to do so. The registered person must 10/11/06 ensure that residents do not have to pay for taxis to attend health appointments and that appropriate transport is booked in advance of their appointments. All care staff must receive 31/12/06 ongoing regular supervision at a frequency that provides them with adequate support. Requirement not assessed at this inspection and is carried forward. The fire risk assessment when 30/11/06 reviewed must detail the findings and areas of compliance. Previous timescale of 30/09/06 not completed, this requirement is carried forward. The fire risk assessment review must also reflect the findings of the fire officer at the recent inspection and detailed in the report. 26 OP38 23(4) Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 31 27 OP38 13(4)(c) Residents’ fire evacuation plans must be reviewed for residents whose needs have changed or for those who have moved rooms. The risk assessment related to food safety must be updated and reflect current practices. 30/11/06 28 OP38 13(4)(c) 12(1) 13(4)(c) 12(1) 17(1)(a) Schedule 3(3)(j) 29 OP38 Previous timescale of 31/07/06 not completed, this requirement is carried forward. The registered person must 02/11/06 ensure that the COSHH cupboard is kept locked at all times, as advised at time of inspection. The registered person must 02/11/06 ensure that following any accident at the home that an accident report form is completed; where serious injury is sustained an accident investigation and report must be completed. The Commission must be informed of the outcome of the investigation. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 32 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. Extracts may not be used or reproduced without the express permission of CSCI Lansdowne Road, 75-77 DS0000016836.V314812.R01.S.doc Version 5.2 Page 33 - 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. 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