Inspection on 08/12/05 for Little Ashmill RCH

This inspection was carried out on 8th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Little Ashmill RCH 29/11/07

Little Ashmill RCH 07/12/06

Little Ashmill RCH 04/08/05

Little Ashmill RCH 30/11/04

Little Ashmill RCH 08/06/04

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

CARE HOME ADULTS 18-65 Little Ashmill RCH 21 Stanhope Way Great Barr Birmingham West Midlands B43 7UB Lead Inspector Maggie Bennett Announced Inspection 8th December 2005 08:30 Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 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 Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 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 Adults 18-65. 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. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Little Ashmill RCH Address 21 Stanhope Way Great Barr Birmingham West Midlands B43 7UB 0121 360 5842 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) Mrs Tuula Marjukka Khan Mr Robin Ballantine Care Home 5 Category(ies) of Physical disability (5) registration, with number of places Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the two damaged easy chairs in the lounge are replaced with chairs in good condition. Age Range 18-65 years That the Landry Floor is made impermeable. Date of last inspection 4th August 2005 Brief Description of the Service: Little Ashmill is registered to care for five people between the ages of 18 and 65 who have a physical disability. The property is a detached house, which has been extensively modernised and refurbished to meet the needs of this service user group. It is situated in a residential area in Great Barr and has shops and a public house nearby. All service users have their own bedroom, which is provided with an en suite shower and toilet. All rooms are designed to be accessible to those using wheelchairs. There is a vertical lift to the first floor. The laundry is reached via an outside path and is therefore not accessible to the service users. Those using wheelchairs would be unable to prepare meals in the kitchen. Little Ashmill is comfortable and well equipped and because of its smaller size, achieves a homely atmosphere. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on a weekday between 8.30 a.m. and 6.00 p.m. Prior to the inspection, a questionnaire was completed by the Registered Manager. All the service users were at home during the day and all were spoken to apart from one, who was unwell. The services of a British Sign Language Interpreter were used for one service user. During the course of the day the care plans of the service users were seen, in addition to daily records. Discussion took place with staff members and the manager of the home. There were no relatives or friends visiting during the inspection. Various documents were inspected during the day and a tour took place of the building. The medication and accompanying records were seen. What the service does well: What has improved since the last inspection? The registered manager has produced the Service Users’ Guide in different formats to suit the needs of the individuals at the home. There has been some progress on the development of care plans. There is evidence that service users have been more involved in their care planning and have signed the plans. Since the last inspection service users have attended educational and advisory training with regard to intimate personal relationships and sexuality. Two of the requirements made at the last inspection with regard to medication administration have been met. The third requirement was that staff take part in accredited medication training and this has been arranged for the New Year. A new carpet has been fitted in the lounge. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 There is a Statement of Purpose and Service Users’ Guide in place. The latter has been produced in different formats to assist prospective service users to make an informed choice about whether they wish to live at Little Ashmill. There are sound assessment procedures in place to ensure that no prospective service user moves to the home unless the home can meet their needs. EVIDENCE: Standard 1 is now met. The registered manager has produced the service users’ guide in different formats to suit the needs of the individuals living in the home. The guide is available on tape and also in Makaton symbols (which, although not ideal, should assist the service user who uses Makaton). Where neither of these formats has been appropriate, the registered manager states that the guides have been read to the service users. Standard 2 was not assessed as no new service users have been admitted to the home since it opened. At that time, however, all service users received a proper assessment. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Although there has been some progress on care planning, more is needed to ensure that the plans are dynamic working documents, which provide staff with the up to date information they need to satisfactorily meet the service users’ needs. Service users are assisted and encouraged to make decisions about their day to day lives. This may involve taking risks. Risk assessments need to be regularly reviewed to ensure that they present an up to date picture. EVIDENCE: All service users have care plans, which are based on their individual assessment information. Each service user has a copy of their care plan in their room. The plans contain a manual handling risk assessment. It was noted at the last inspection that the Registered Manager had been working on these care plans and was in the process of reviewing, updating and making plans available in accessible formats. Some of this work has been done and there is evidence that some service users have been involved in their care planning and have signed the plans. There is full information in the plans of the service users’ daily routines and of the assistance they need. In addition each service user has a daily log, which gives an up to date picture. The Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 10 majority of the service users have had review meetings, in which they have been involved. No copies of review notes, however, have been received from social workers and this needs following up. There is no evidence that risk assessments are regularly reviewed. Only limited progress has been made in collating the care plans into clear and up to date working documents and this could be due to the fact that the Registered Manager has been required to cover shifts on numerous occasions (see Standard 31). It remains a recommendation that care plans contain more information on service users’ individual goals and aspirations. At present a key worker system is not in place and this should be introduced as soon as possible. Service users’ views on how they wish to be assisted are stated in their care plans. One service user has received help from an Advocate. The registered manager gave an example during the inspection of how a service user was enabled to make a choice about medical screening. Staff were observed during the day to be asking service users about their views and decisions on forthcoming events. All service users have their own bank accounts and are supported in the management of their finances. The home does not act as Agent or Appointee for any of the service users. Risk assessments are undertaken for all service users (these need to be regularly reviewed – See Standard 7, above). None of the present service users wish to go out alone and all need assistance. There is a Missing Person Procedure in place. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 15 and 17. Service users take part in some local activities, including the local Pub and attendance at Church. A number of appropriate leisure activities are offered, including holidays. Service users are assisted to maintain family links and friendships and are offered advice with regard to intimate relationships. Service users are offered a variety of foods and the home is well stocked with food. There is scope for more discussion with service users about healthy eating and for involving them more in menu planning. EVIDENCE: Service users have access to a number of local facilities, including the local Pub. Two service users attend the local Church each Sunday and additional staff are brought on duty at this time to facilitate this. For trips further afield, Ring and Ride and taxis are used and when available, the home has use of the minibus from its sister home, Ashmill. When speaking with staff, one said that she thought one of the service users would benefit from going to a local hairdresser, rather than having her hair done at the home. The manager is recommended to discuss this with the service user. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 12 From discussion with the service users, staff and manager it is clear that a number of leisure activities are provided, both in and outside of the home. The home is recommended to record all these activities. Service users’ hobbies and interests are recorded in their care plans. In house activities have included a Halloween Party, birthday celebrations, a Dinner Party and art and cooking. Outside trips have included one service user being taken to cricket and football matches. Other trips have included dog racing, shopping and meals out. Two service users have a holiday planned for March 2006 and the manager is discussing an alternative holiday with another service user. Leisure activities are regularly discussed at service users’ meetings. Some staff felt at the last inspection that there could be an improvement in leisure activities and this was echoed on this occasion, with one member of staff feeling that service users would benefit from a regular programme of activities when they spent their days at Little Ashmill. Service users are assisted and encouraged to maintain family links and links with their friends. Some families visit and one service user telephones a relative every evening. If service users do not wish to see particular visitors, their wishes are respected and an example of this was given during the inspection. During their social visits outside of the home, service users have the opportunity to meet with people who do not have their disability. The home has a clear policy on service users’ rights to develop and maintain intimate personal relationships of their choice. All service users have attended a training course with regard to sexuality and related issues. This training was given by professional trainers and care staff were not in attendance. Service users spoken to said that they liked the food, although they said that some staff were better cooks than others! Food is regularly discussed at Service Users’ Meetings and evidence of this was seen in the notes. There are menu plans, but these are not always stuck to, as service users often change their minds. During the inspection one service user was assisted to the kitchen and shown the various foods on offer, from which she chose her evening meal. There were ample supplies of food in the home, including fresh fruit and vegetables. It was noted, however, that main meals are often prepared packs. One staff member felt that there was too much “junk food”. It is recommended that more detailed discussions are held with service users, including advice with regard to healthy eating. If possible, service users should be more involved with menu planning and shopping. The kitchen was clean and in good order. There was evidence that fridge and freezer temperatures are taken regularly. The last recorded date, however, was 24th November 2005. These temperatures must be taken and recorded each day. The home must purchase a probe and take the temperature of cooked meats before serving. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Generally the home’s policies and procedures with regard to medication administration are sound and protect service users. The present procedure with regard to tablets taken out of the home needs to be improved so that secondary dispensing does not take place and the service user involved is fully protected. EVIDENCE: Standards 18 and 19 were not inspected on this occasion as they were met at the unannounced inspection in August 2005. There were, however, some concerns noted with regard to staff practice with moving and handling (see Standard 31 (below). Three statutory requirements were made with regard to Standard 20 (Medication) at the last inspection. Two of these requirements are now met. The requirement with regard to staff accredited training will be met in the New Year. All staff who administer medication will be taking part in accredited medication training, a Distance Learning course provided by Solihull College. Service users’ consent to medication has been obtained and this is recorded in their care plans. None of the present service users take charge of their own medication, although all have a lockable facility in their rooms, should they wish to do so. The medication administration record sheet folder must contain a photograph of each service user. The home uses a monitored dosage system. The medication and record sheets were seen at the inspection and Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 14 there were no discrepancies. At present the home is engaging in secondary dispensing for one service user who attends College. The home must speak with the Pharmacist and arrange for a separate container for this lunchtime medication, so that secondary dispensing is not required. When Controlled Drugs are taken from the home for such trips out, the C.D. Register must be completed on each occasion and there must be a clear picture of how many tablets leave the home and how many return. The home has appropriate storage in place for Controlled Drugs. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. There is a complaints procedure in place and evidence that service users’ concerns are listened to and acted upon. The home’s Adult Protection Procedure and related procedures need to be amended as the current documents are not in line with local Social Services procedures and the Department of Health guidance. Current practices for the safekeeping of service users’ monies are poor and must be improved to ensure accurate records. EVIDENCE: The home has a Complaints Procedure and this is available in Makaton symbols. Both are on the wall of the home in the downstairs hall. The registered manager states that the procedure has been explained verbally to service users. No complaints have been received by the home within the last 12 months. Neither have any been received by the Commission. At the inspection in August 2005 a service user said that she had in the past been able to discuss a concern with the manager. An advocacy service is available locally and this would be accessed if a service user needed assistance with a concern. At present the home does not have a system in place in which to record any complaints made and how they have been dealt with. This needs to be provided. The home have an Adult Protection Procedure, but this must be updated and amended to ensure that it is in line with local Social Services procedures and with the Department of Health Guidance, “No Secrets”. The procedure needs to clearly state the correct steps to be taken following an allegation or suspicion of abuse. In the home’s history there has been one allegation of abuse and this was dealt with in the correct manner and satisfactorily resolved. There is a Whistleblowing Policy in place. The home’s policy on physical and verbal aggression by a service user is weak and must be amended with details Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 16 of how such behaviour is to be managed. The home must have a clear policy with regard to physical restraint. There are policies in place with regard to service users’ monies, but records were found to be in poor order at the inspection. A full audit of service users’ monies must be carried out and the monies and accompanying records must be checked for accuracy on a regular basis. The home’s insurance covers £1,000.00 of service users’ personal possessions. The home has a policy in place, which precludes staff involvement in making or benefiting from service users’ wills. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 and 30. Little Ashmill is generally well maintained and is warm, clean and comfortable. The provision of double glazed windows to the ground floor of the property is now urgent, as some service users feel cold in their rooms overnight. EVIDENCE: Little Ashmill was found to be clean, comfortable and warm at the time of the inspection. There is wheelchair access to all communal areas, but service users are unable to use the laundry and kitchen, as neither are safely accessible to wheelchair users. The home was inspected by the Fire Officer in September 2005 and the registered manager states that the recommendations made at that time have now been met. Throughout the home there are a number of items of equipment to assist service users. These include a vertical lift, an assisted bathroom, en suite showers, a call alarm system and lowered light switches. There is storage and recharging facilities for wheelchairs. Flashing light fire alarms have been provided in rooms where service users are hard of hearing. All service users have their own single rooms, which are equipped with suitable en suite facilities. All bedrooms were seen during the inspection and all were comfortably furnished and individually decorated. First floor rooms have been fitted with double glazed windows. Those on the ground floor have not and one service user complained that she was often cold at night. This needs to be resolved and new double glazed windows must be Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 18 fitted as quickly as possible. The home must also carry out a risk assessment where beds are placed against radiators and ensure that radiators are covered if the risk assessment indicates this. A second service user made a number of suggestions as to how her room could be changed in order to help increase her independence. These suggestions have been passed on to the registered manager, but include moving the position of the hand rail in the wardrobe so that she can hang up her own clothes. She felt she needed more storage space. She also pointed out that the emergency alarm call point was on the wrong side of the bed for her as she had difficulty in using her left arm. The laundry is not ideally situated and has to be approached from the back door along the garden. This precludes it from being accessible for service users. There are hand washing facilities in the laundry and the floor covering is impermeable. The washing machine has a sluicing facility. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. Staff enjoy their work and are keen to provide a good standard of care. They have not, however, been provided with sufficient opportunities for in depth training in the needs of their service user group. Care staff levels are adequate, but this is at the expense of managerial time (see Standard 38 below). Recruitment procedures are sound and protect service users. Staff are not receiving sufficient supervision or opportunities to air their views at regular meetings and this has an effect on the standard and consistency of care offered in the home. EVIDENCE: The home has not yet established a key-worker system. Staff shortages mean that the registered manager is covering a large number of shifts as a care worker, in order that the home can be sufficiently staffed. On the week prior to the inspection the manager had worked as a carer on double shifts on three days and had also worked a shift on a Saturday and Sunday. He is unable to fulfil his managerial duties mainly because of this and care planning is subsequently suffering. The staff spoken to during the inspection were found to be enthusiastic and were observed to have an excellent rapport with the service users. One staff member, however, felt that not all of her colleagues were conversant with the service users’ needs and care plans. She gave an example of a member of staff moving a service user on her own, when the Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 20 care plan clearly stated that two carers were needed in order to safeguard the service user. Very few of the care staff have received specific training in the needs of people with physical disabilities and this limits their knowledge and competence. The registered manager states that this was to have been provided by himself, but he has not had the time. Advice and assistance is available locally from physiotherapists, occupational therapists and speech therapists. The registered manager feels that the home generally has a good working relationship with social and healthcare professionals, although there have been some problems of late in accessing social workers. Currently there are 5 staff who hold the NVQ level 2 qualification. Unfortunately the home have lost some of its former staff who had NVQ2. The registered manager states, however, that 75 of the remaining staff will be on NVQ training by February 2006. Rotas show that the home is adequately staffed with care staff (3 on daytime shifts and 2 waking night staff). There are no domestic staff employed, care staff carrying out cleaning and cooking duties. Extra staff are placed on duty to cover social activities, such as Church attendance on a Sunday. As noted in Standard 31 (above), however, recent staff shortages have meant that the registered manager has carried out a number of duties as a care worker and whilst this is acceptable and good practice on some occasions, he does need time to carry out managerial duties. 2 staff have left since the last inspection in August 2005 and there is currently one person on long-term sick leave. Specialist services are available locally and some service users are seen by a speech and language therapist. Although the staff team reflects the cultural diversity of the service user group, it does not reflect the gender composition, as the registered manager is the only male member of staff. Staff meetings have not been taking place on a monthly basis and there is very little improvement here since the last inspection. Staff use a variety of methods to communicate with service users and Makaton training is to be arranged. One service user is awaiting an electronic communication aid. The files of some newly appointed staff were seen at the inspection. These showed that all the required recruitment checks had taken place before the staff commenced their duties. The home are reminded that Criminal Records Bureau checks are not “portable”. As stated at the last inspection, all staff files must contain a photograph of the staff member. Service users are invited to meet potential staff and give their views on the person’s suitability to work at the home. Staff are given copies of the General Social Care Council Code of Conduct. All appointments are subject to a 3-month probationary period. As at the last two inspections, the home do not have a training and development plan in place. This must be developed and a copy forwarded to the Commission. The home do, however, have in place an individual training and assessment profile for each member of staff. New starters do take part in induction training, but this is not to Skills for Care Specifications and needs to Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 21 be more comprehensive. Staff have received training in equal opportunities. Staff have not been receiving supervision six times a year. A staff member spoken to had had only one supervision session in six months. As stated in Standard 23 (above), the home’s procedure for dealing with physical aggression must be improved. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 and 42. The manager is popular and committed, but needs to spend more time on his managerial duties in order to be able to provide clear leadership and a development plan and vision for the home. There are good procedures in place to protect the health, safety and welfare of service users and staff. The induction training of new staff in safe working practice topics needs to be to Skills for Care specifications. EVIDENCE: The registered manager is to commence the Registered Managers’ Award and NVQ4 Award in February 2006. He is very experienced in the care of people with a physical disability and is liked and respected by the service users. Although work has commenced on improving care planning and other systems in the home, this has been curtailed because the manager has spent a great deal of time on care duties. The manager has been unable to develop a clear plan for the future, based on the views of service users, other stakeholders and staff. At the last inspection, in August 2005, the staff group at that time had taken part in moving and handling, food hygiene and infection control training. The Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 23 training and development plan, to be forwarded to the Commission, must indicate the numbers of staff who currently hold up to date qualifications in moving and handling, fire safety, first aid, food hygiene and infection control and the dates when future training is to take place. 8 staff have taken part in fire safety training this year. Records seen verify that fire alarm tests, emergency lighting tests and fire drills are carried out at the required intervals. The Fire Alarm system and Emergency Lighting system were checked and maintained in July 2005. The home have a Fire Risk Assessment in place, which was carried out by a professional company. Evidence was seen that the lift was serviced in November 2005. Evidence was seen at the last inspection of regular gas safety checks, legionella checks, water temperature checks and the testing of electrical equipment. At that time the registered manager was developing risk assessments for safe working practice topics. Progress has been made, but these have not yet been completed. As stated in Standard 35 (above) induction training must be to Skills for Care specifications on all safe working practice topics. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 2 2 2 3 2 1 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Little Ashmill RCH Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 2 2 X X X 2 X DS0000043608.V261812.R01.S.doc Version 5.0 Page 25 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Service users plans of care must be in an accessible format. (Previous timescale of 30/09/05 not met). Service users’ plans of care must contain evidence of six monthly reviews and of regular reviews of risk assessments. Care plans must be clear, up to date, working documents. Fridge and freezer temperatures must be taken daily and recorded. A probe must be purchased and the temperature of cooked meats taken. The registered manager must speak with the Pharmacist and arrange for a separate medication container for a service user to take to day care. Secondary dispensing must not take place. The medication administration records folder must contain a photograph of each service user. Timescale for action 31/01/06 2. YA6 15 31/01/06 3. 4. YA6 YA17 15 16(2)(j) 31/01/06 08/12/05 4. YA20 13(2) 08/12/05 5. YA20 13(2) 31/12/05 Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 26 6. YA23 13(6) 7. YA23 12(1) 8. YA23 12(1) 9. YA26 23(2)(p) 10. YA26 13(4)(a)(c) 11. YA31 18 13(5) 12. 13. 14. YA32 YA36 YA34 18(1)(c) 18 19 4.6 The home’s Adult Protection Procedure must be amended and updated to ensure that it is in line with local Social Services procedures and the Department of Health Guidance, “No Secrets”. The home’s policy on physical and verbal aggression by a service user must be amended. There must be a clear policy with regard to whether or not physical restraint is used. An audit of service users’ monies and accompanying records must be carried out. These records must be kept up to date and checked on a regular basis. The two ground floor bedroom windows must be replaced with double glazed windows. Where beds are placed against radiators the home must carry out a risk assessment. Radiators must be covered if the risk assessment indicates this. The registered manager must ensure that staff are conversant with care plans and of the needs of individual service users. Staff must ensure that service users are moved safely. Staff must receive training in the needs of people with physical disabilities. Staff meetings must take place on a regular basis. Staff files must contain a photograph of the individual member of staff. 31/01/06 31/01/06 31/12/05 31/01/06 31/01/06 08/12/05 28/02/06 31/01/06 31/01/06 Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 27 15. YA35 18(1)(c) 16 YA36 18(2) 17 YA37 12(1)(a) 18 YA42 18(1)(a) A training and development plan for the staff group must be forwarded to the Commission. (Previous timescales of 28/05/05 and 31/08/05 not met). Care staff must receive regular supervision. Staff meetings must take place on a regular basis. (Previous timescale of 31/08/05 not met). The registered manager must be enabled to have the time to engage in managerial duties. Whilst it is good practice to spend some time on care duties, this is currently excessive. Care staff must receive regular training in moving and handling, first aid, food hygiene and infection control. Certificates to verify this training must be available in staff files. 31/01/06 31/01/06 31/01/06 31/01/06 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 3 4 5 Refer to Standard YA6 YA6 YA7 YA14 YA17 Good Practice Recommendations It is recommended that informal reviews take place each month and that this is recorded. It is recommended that care plans contain more information on service users goals and desired outcomes. It is recommended that the registered manager discusses with a service user her wishes with regard to hairdressing. It is recommended that all leisure activities are recorded. It is recommended that discussions takes place with service users with regard to healthy eating and that, if possible, service users are more involved with menu planning and shopping. DS0000043608.V261812.R01.S.doc Version 5.0 Page 28 Little Ashmill RCH 6 7 8 9 10 YA22 YA26 YA33 YA14 YA19 The home should have a system in place in which to record any complaints made and how they have been dealt with. It is recommended that the Registered Manager discuss room alterations and additions with a service user (name given to Registered Manager). It is recommended that a key worker system is introduced. It is recommended that further discussion about leisure activities take place with service users and during Staff Meetings. It is recommended that the G.P. be requested to provide each service user with an annual health check and review of medication. Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Little Ashmill RCH DS0000043608.V261812.R01.S.doc Version 5.0 Page 30 - 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. 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