Inspection on 30/09/05 for Mali Jenkins House

This inspection was carried out on 30th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Mali Jenkins House 30/08/07

Mali Jenkins House 04/01/07

Mali Jenkins House 05/04/05

Mali Jenkins House 02/09/04

Mali Jenkins House 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Mali Jenkins House The Crescent Chuckery Walsall West Midlands WS1 2BX Lead Inspector Deborah Sharman Unannounced Inspection 30th September 2005 8:45 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 Mali Jenkins House DS0000020817.V256367.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 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. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mali Jenkins House Address The Crescent Chuckery Walsall West Midlands WS1 2BX 01922 746246 01922 610720 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) Care First Partnerships Limited, (BUPA) John Grooms Housing Association Miss Gillian Howarth Care Home 20 Category(ies) of Physical disability (20) registration, with number of places Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age above 40 years Date of last inspection 5th April 2005 Brief Description of the Service: Mali Jenkins is a detached property that was originally built for use as a sheltered housing complex. The home provides 20 single rooms, all of which are ensuite. The home also offers respite and day care placements. The home provides care for service users with neurological illnesses predominately Parkinson’s Disease. The home is situated just off the main road and is close to a busy bus route, which goes into Walsall Town centre. There is off road parking at the front of the property with a small garden to the rear. All rooms and communal areas are on the ground floor. The home is well laid out with adaptations for wheelchair users and people with mobility difficulties. There are 2 assisted bathrooms and one assisted toilet. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced which means that the proprietor, Manager, staff and service users did not have prior notification. The inspection took one Inspector ten hours beginning at 8.45am and finishing at 6.45pm. At this inspection the Inspector learned that the Registered Manager was no longer in post. The Inspector was able during the course of the inspection to interview in detail the Interim or Acting Manager, a senior staff member, and a service user. In addition the Inspector observed lunchtime, speaking to 4 service users and the new chef during the course of lunch. The administration of medication was observed and the staff member administering medication was also spoken with. In addition documentation was assessed in order to support the assessment of performance against a range of standards. Progress against some but not all previous requirements was assessed due to time restrictions resulting from a range of unanticipated challenges that arose during the course of the day. What the service does well: The premises are bright and airy and well decorated with good quality soft furnishings. All service users spoken to spoke highly of the food provided and appreciated the quality, quantity and choices available. A further service user also praised the approach of most staff stating ‘perfect’ in reply to the question ‘are the staff polite and respectful?’ This service user also commented on the ‘personal touch’ provided by staff which she felt came from being in a smaller home. The service user provided an example to illustrate this. She very much appreciated being accompanied by a carer to visit a friend by taxi for the afternoon. The service user said that she feels safe at the home. A staff member who has many years experience in a variety of care homes said ‘this is one of the better homes I have worked in. This is more like a family and I would be happy for my mum and dad to come here – they care for the residents and the families are happy’. The Acting Manager worked openly and positively with the Inspector during a long and difficult day. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 7 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 Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 8 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): 3, 5. No service user moves into the home without having his / her needs assessed and the opportunity to visit and assess the suitability of the home. The home is not however formally assuring service users prior to admission that their assessed needs can be met by the home. EVIDENCE: Records showed that service users are only admitted following assessment. Potential service users are also able to visit prior to deciding to move in. As the home has two respite beds both service users whose assessment prior to admission was case tracked by the Inspector had been respite clients prior to moving in permanently which helped their decision to move in permanently. Service users are not being provided with written confirmation that their needs can be met by the home. Previous inspections have identified the need to ensure that care plans are in place to meet all needs identified through assessment. A new service user was admitted on the day of inspection and the Acting Manager made time to greet him personally. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 9 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): 9 Service users are not protected by medication administration practice within the home. EVIDENCE: The administration of medication was assessed. The Inspector observed a senior staff member administer medication in the dining room at 1.00pm. The carer handled medication before putting it into the tot and signed for the medication dispensed prior to taking the medication to the service user. Neither of these actions are good practice. The tot was then put on the dining table and left for the staff member seated at the dining table supporting service users to eat referred to as ‘the feeder’ to administer. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 10 This is not safe practice jeopardising the safety of other service users at the table and risking mal administration. Upon questioning the senior staff member about this practice she said that she had only signed for it prior to administration because it was to be given to the ‘feeder’ to administer. This did not demonstrate sufficient knowledge of her role or responsibility. When asked whether she had received any medication training she confirmed that she had not but added that she ‘hasn’t done too badly so far’. The Manager identified with the concerns raised by the Inspector saying that this practice was common practice amongst many of the staff group and that she had been trying to improve practice. Medication is stored in an appropriately secured medication trolley and the carer was noted to lock the trolley on each occasion that she left it ensuring that stored medications were not accessible. The home receives pharmacy support visits and records of these visits are available within the home. A service user who spoke with the Inspector reported no problems with the administration of her medication. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 11 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): 13, 14, 15 Service users maintain contact with family / friends / representatives and the local community as they wish. Service users are in general helped to exercise choice and control over their lives. Service users receive a wholesome and appealing balanced diet in pleasing surroundings. EVIDENCE: A service user spoken to confirmed that visitors are able to visit at any reasonable time and that she can receive her visitors in either communal areas of the home or in her own room, which she considered home if she wished to. She also confirmed that she can choose whom she sees and does not see and that there are no restrictions on visits. She was delighted that a carer had made a visit to friends for her possible by accompanying her in a taxi and staying with her for the two and a half hour visit. The service user described this as ‘the personal touch’. The service user confirmed that she receives a monthly communion visit from a representative of her church and enjoyed regular recital visits from the visiting reform church. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 12 A service user interviewed confirmed that she handles her own financial affairs with the support of an independent executor who she appointed and who visits her weekly at Mali Jenkins House to update her re: her financial affairs. She confirmed that the home holds a small amount of personal spending money on her behalf and that she is happy for them to do this. She confirmed that she had been able to bring personal effects including small items of furniture with her and this was evident within her room. The service user said that from her professional background she believed that she could access her personal records but that the home had not informed her of this right. In summary the service user said that ‘choices are not restricted’ although her preference would be to be woken up at 8.30a.m. rather than 7.30am. This was fed back to the Interim Manager who said that she had to get up at 7.30 to facilitate her medication routine but agreed that this could be discussed and reviewed with the GP. New dining furniture has been provided since the last inspection. The menus seen were varied and the lunchtime meal observed was well presented with generous portions. Three full meals are offered plus supper with the main meal of the day being in the evening as this is felt to benefit service users with Parkinson’s Disease. Lunch was three courses. Service users confirmed that they are consulted in the morning about their meal choices for the day and confirmed that they receive the meal they have chosen. Unfortunately on the day of inspection the menu was not adhered to and service users who were expecting pizza received quiche for reasons unknown even to the Interim Manager and the chef. A service user who chooses to eat in her room told the Inspector that she had been informed that there had been such a high demand for the pizza that there was not enough left and that consequently the quiche was the available alternative. The Inspector was able to tell her that pizza had not been available at all. The menu was not available or accessible for service users. Mealtime was observed to be calm and pleasant with sufficient space at tables. Five staff were supporting lunch and were seen to discreetly support those service users requiring assistance at the table. Adapted equipment e.g. cups with spouts were available for those service users who require them. The Inspector spoke to four service users seated at one dining table all of whom expressed satisfaction with the meals. A further service user spoken to added that she chooses to eat her breakfast in her bedroom, that hot and cold drinks are available at all times and that food served is always hot. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 13 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): Systems are not in place to sufficiently protect service users from abuse. EVIDENCE: It was not planned to fully assess Complaints but whilst case tracking a written complaint was found in the file of a service user who had written the complaint whilst on receiving respite care and prior to moving in permanently. The complaint detailed concerns about staffing levels and being ignored by four carers when taken ill. The complainant who addressed the comments to the previous Manager noted that she felt ‘neglected and embarrassed’. Whilst the complaints log appeared to be well maintained with many complaints listed and noted as addressed within appropriate timescales there was no record of this complaint having been received or investigated. Inspection showed an adult protection incident occurred on 29th August 2005 and 5th September 2005. Omissions in practice were identified following these incidents. A staff member reported thinking that she had seen possible abuse on 29 August 2005. It seems that there was a delay in reporting this first incident to the Manager who according to records was not informed until 1st September 2005. Adult protection proceedings were not implemented in light of this suspicion of potential abuse and the Acting Manager who acknowledged the incident as abusive advised staff to monitor the situation, which failed to protect the service user from any future potentially abusive situation. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 14 A carer again reported witnessing the same act on 5th September 2005 and fetched a senior staff member who also states she witnessed this and challenged the alleged perpetrator. The times of events are unclear as they are not included in written statements (and a statement was not obtained from the senior staff member) but from discussion with the Manager it appears that the Manager who was at home was not informed of this second incident until after the service user had been discharged. Whilst it is positive that staff on duty recognised what they believed they saw was abusive, actions taken were not appropriate or timely. • • • • • The police were not called to ensure the service users immediate protection. Medical attention was not considered or sought. Social Services were not informed until the following day. Commission for Social Care Inspection has not been informed under Regulation 37. It appears also that Senior Managers at BUPA have not been informed. Lines of accountability are not clear when the Manager is not on duty and telephone numbers for more senior company Managers were not available or known to staff whom the Inspector spoke to. A high turn over of staff means that a large proportion of the team and senior team are new and have not been sufficiently prepared to know what action to take. The home’s Adult Protection Policy and procedure whilst it does not sufficiently guide staff or Managers had not been adhered to and is not consistent with Local Authority guidelines that were also not available within the home. There is in addition, not a copy of the Department of Health’s ‘No Secrets’ document within the home. The Whistle Blowing Policy is also inadequate suggesting that staff ‘should’ rather than ‘must’ report incidents. Furthermore whilst the Whistle Blowing Policy refers to external agencies offering a ‘sympathetic ear’ it does not advise staff as to the role of these external agencies in such matters or advise of the contact details. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 15 The homes policy on abuse states that ‘training on the problem of abuse is available to all staff’. It has not been made available as per policy. The Acting Manager received adult abuse training in 2001 prior to the Care Standards Act and the introduction of multi agency protection procedures for adults. She has therefore not received up to date training. Care staff have not been provided with adult abuse / protection training of any kind. The policy on restraint was missing. The Acting Manager said that the home does not need to use restraint but was unsure about her responsibilities should restraint prove to be necessary. Training has not been provided. The home holds some monies belonging to service users to enable them to buy small personal effects and services e.g. toiletries and hairdressing. Records, storage and practice in relation to the management of service user finances is good. Balances were checked against cash in hand with no concerns. The home also holds in safe keeping some service user’s valuables, which are included in a written inventory. They are not identified however within the safe holding and although the service is said to be reviewing its policy on the safe keeping of valuables due to insurance limitations, whilst the goods are held, a system must be employed to clearly identify who they belong to. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 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): These Standards were not assessed. EVIDENCE: These Standards were not assessed. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 17 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): 29 Recruitment practices are failing to protect service users and are putting service users at risk. EVIDENCE: There has been no improvement since the last inspection. Six new staff (three seniors and three carers) have been appointed and have commenced employment since the last inspection. As at the previous inspection Criminal Record Bureau checks have not been received prior to employment and not received by the date of this inspection. For one further new staff member (who has since left employment) there was no evidence that a Criminal Record Bureau check had been sent for. There was also no evidence that POVA first checks have been carried out for any of these six staff, contrary to previous requirement and contrary to the provider’s undertaking in its subsequent action plan submitted to CSCI. Identifying photographs of staff remain unavailable on staff files again contrary to the previous action plan submitted by the provider. The homes recruitment policy dated January 2005 indicates that the provider is aware of the need for Criminal Record Bureau checks prior to employment of staff. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 18 Risk assessments have not been undertaken to measure risk levels and to control risks identified by the employment of unchecked staff. The Commission for Social Care Inspection was not informed under Regulation 37 of any extenuating circumstances that warranted the employment of a significant number of staff without the necessary checks. As three unchecked staff are senior staff and with the absence of a Deputy Manager post there are not sufficient arrangements in place for the adequate supervision of these staff which would have been highlighted by risk assessment. Two new seniors are on occasions working on shift together without appropriate supervision at all times. It is of further concern that these senior staff members for whom there is not a Criminal Record Bureau check in place are administering medication. An ex staff member (who only worked for a few shifts) for whom there is no evidence that a Criminal Record Bureau check has been sent for and for whom one has not been received arrived at the premises during the inspection and demonstrated characteristics that would cast doubt on her fitness to work in a care home. The Acting Manager was forced to dial 999 and the Police attended the premises. The Manager also informed the Inspector that prior to resigning this staff member had during one shift left the premises unknown to any staff member leaving pots boiling in the kitchen and a joint in the oven. This gave a high risk of fire and threatened the safety of staff and service users. It was concerning that following this incident the staff member was permitted to return for a further shift before deciding that she no longer wished to continue in the post. This incident highlights shortfalls in the recruitment (and disciplinary) practice at the home. Whilst the home does not currently have any volunteers the Acting Manager said that there had been volunteers earlier in the year and that Criminal Record Bureau checks had not been carried out. The high turnover of staff further fails to protect service users. A fifth of the entire team are new since the last inspection and the Acting Manager attributes this to poor medication and protection practice. It was assessed at this inspection that Mali Jenkins House currently does not have 50 of its care staff qualified to NVQ level as required by national Standard. The provider has stated that this target has been previously met but the turnover in staff recently has reduced the number of appropriately qualified staff and the requirement to meet the standard remains. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 19 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): 35, 38. Service users financial interests are generally safeguarded. On the whole the premises are maintained to protect the safety of service users with some significant exceptions that do place service users at increased risk. EVIDENCE: Service user financial records and safekeeping was assessed. Neither the Manager nor provider is the appointee for service users, which helps to protect service users interests. Small amounts of money are held in safe keeping on service users behalf to pay for toiletries and hair appointments etc. Written records of all transactions are appropriately maintained, signed by two people and were seen by the Inspector. Personal allowances are individually maintained and are not pooled. Receipts are kept to account for spending. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 20 Secure facilities are available for safekeeping to which only the Interim Manager has access. Valuables are currently held by the home on behalf of service users but this is under review. Valuables are recorded and not pooled but individual bags and boxes are not identified as to whom they belong. Safety was partly assessed at the previous inspection. Therefore maintenance records were assessed at this inspection. Records were generally satisfactory evidencing that steps are taken to ensure that the premises are safely maintained. The following was not available; a water legionella test. A telephone call on the day to the contractor confirmed that this had not been carried out, as it had not been requested. Fire alarm system checks carried out by a contractor in March 2005 did not include bedrooms. The Contractor was supposed to return but did not. A five year total electrical safety installation check was undertaken recently in May 2005 with seven recommendations as outcomes from this including 2 assessed by the contractor as ‘urgent’, 3 ‘requiring improvement’ and 2 assessed as ‘not complying’. Telephone calls on the day of inspection achieved an undertaking that these would be met ‘at most within the next 3 weeks’ and were therefore not included as immediate requirements. It is however concerning that electrical work assessed as ‘urgent’ has not been addressed within six months of identification. Kitchen temperature maintenance records (both hot and cold) are appropriately maintained protecting service users from the risk of food-induced illness. Three first aid boxes were assessed. One was new and was well stocked. The other two including one kept in the kitchen were as good as empty and would not serve a purpose in an emergency. Five out of twenty nine staff are first aid trained which does not ensure that an appropriately trained staff member is available on every shift. The presence of a fire risk assessment was not assessed at this inspection. However staff informed the Inspector that a fire drill had not taken place for 12 months. Records appeared to support this. The Inspector was informed that this was because nobody had done the training and therefore nobody knew how to do a fire evacuation. However the maintenance person said that he and another staff member undertook this training on Friday 23 September and that he planned to undertake a fire drill soon. There is a high number of falls for a small home incurred by service users, which the Acting Manager partly attributed to the nature of Parkinson’s Disease, which the majority of service users have. Records show that during the 12-month period 30.9.04 to 30.9.05 one hundred and fifty one accidents happened with the majority being falls. Records for the previous 6 months showed all accidents to be falls. A service user case tracked had had seven falls in Six months. Risk assessments are in place but should be reviewed to ensure that all control measures are in place to further minimise any risks. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 21 The home has recently acquired 2 cats one of which remains at the home. The company policy on animals in the workplace states that ‘a risk assessment must be completed for any pet entering the home’. A risk assessment has not been undertaken. The Inspector’s concern is that a cat poses a tripping hazard in a home with a high number of falls. Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 1 x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 2 x x 2 Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 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 OP7 Regulation 14 Requirement The Registered Manager must ensure that a comprehensive assessment is completed for all service users. Not Assessed at September 2005. The Registered Manager must ensure that care plans are implemented for all assessed needs. The Registered persons must obtain a written agreement with regards to JR blood sugar levels and a care plan is written and implemented. Not assessed at September 2005 The Registered Manager must ensure that care plans are reviewed monthly and the date documented. Care plans must be stored securely and locked. Not assessed at September 2005 The Registered Manager must ensure that the home has the appropriate risk assessments. Not Fully Assessed at September 2005 Timescale for action 30/11/05 2. OP7 15(1)(2) sch(3)(m) 30/11/05 3. OP7 15 2(b)(c)(d) 30/11/05 4. OP8 13(4) 30/11/05 Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 24 5. OP8 13(4)( c),12(a) 17(3)( a) 13(4)(c ) 13(2) 6. OP8 7. OP9 8 OP9 13(2) 13(4) 9 OP9 13(2) 12 10 OP15 12 11 OP16 22 (Risk assessment for new cat not undertaken contrary to company policy) The Registered Manager must ensure that service users are weighed on a regular basis. Not assessed at September 2005 The Registered Manager must ensure that daily records show continuation of care. Not assessed at September 2005 All staff must receive accredited administration of medication training. (Previous timescale of 2nd September 2004 not met) To take measures immediately to ensure an improvement in medication administration to ensure the safety of service users. To confirm in writing to CSCI by 3rd October 2005 at 5pm of measures taken to improve practice and reduce risk. Immediate Requirement issued at this inspection, September 2005. To review with the GP the medication administration times for service user SS to facilitate choice and preference. New Requirement at September 2005. To ensure that accurate menus are available and accessible for service users. New Requirement at September 2005. All complaints must be logged and investigated with the outcome recorded. New Requirement at September 2005. 30/11/05 31/10/05 31/12/05 03/09/05 31/10/05 31/10/05 30/09/05 Mali Jenkins House DS0000020817.V256367.R01.S.doc Version 5.0 Page 25 12 OP18 13(6) The home’s Adult Protection policy must be reviewed. The home’s Whistle Blowing Policy must be reviewed. The home’s policy on restraint must be available within the home. A system must be employed to clearly identify who valuables held in safe keeping belong to. New Requirements at September 2005. 31/10/05 13 OP18 13(6) 14 OP18 13(6) To ensure with immediate effect 03/10/05 that all senior staff (including the Acting Manager) at Mali Jenkins House know, as a priority, of action to take in the event of an adult protection concern. To further ensure that contingency arrangements are in place and known to staff to enable them to obtain guidance from senior Managers both during and out of office hours. To communicate action taken in writing to CSCI by 3rd October 2005 at 5pm New Immediate Requirement at September 2005. To book appropriate Adult Abuse 07/10/05 / Protection training for all staff including senior staff and the Acting Manager by 7 October 2005 and to communicate the arrangements made in writing to CSCI by this date at 5pm. New Immediate Requirement at September 2005. The Registered persons must replace the clinical waste holder in the toilet.Requirement made DS0000020817.V256367.R01.S.doc 15 OP19 12(a),14( 4)(a) 30/11/05 Mali Jenkins House Version 5.0 Page 26 16 OP19 23 17 OP28 18 18 OP29 sch 2,19 19 OP29 19 13(4)(c) and not met at April 2005 The Registered persons must address the scuffed and marked grab rails and door frames. Requirement first made and not met at April 2005. The Registered person must ensure that a minimum ratio of 50 trained members of care staff to NVQ level 2 or equivalent is achieved by 2005. (Previous requirement prior to May 2004) The Registered person must ensure that all gaps in employment history are explored and the date in which the POVA check is received is documented and a photo of the staff member is available. Requirement first made and not met at April 2005. Staff must not commence in employment prior to receipt of a satisfactory Criminal Record Bureau check. Risk assessments with control measures must be undertaken and carried out for all staff employed without Criminal Bureau Checks. The existence of POVA checks for these staff must be verified. This must be communicated in writing to CSCI by Monday 3rd October 2005. Measures must be taken to immediately protect service users. New Immediate Requirement at September 2005. 31/12/06 31/12/05 30/09/05 03/10/05 20 OP33 24(1) 21 OP38 18(a),13 The Registered Manager must document all internal audits undertaken. Not assessed at September 2005 The Registered person must DS0000020817.V256367.R01.S.doc 31/10/05 31/12/05 Page 27 Mali Jenkins House Version 5.0 (5)13(4) 22 OP38 23(4(d) 23 OP38 23 13(4) 24 OP38 13(4) 25 OP38 13(4) 18 26 OP38 23(4)(e) ensure that all staff receive mandatory training. Requirement first made and not met at April 2005. The Registered persons must ensure that fire drills cover all of the shifts. Immediate Requirement at September 2005. To ensure that the seven improvements identified as required by contractors during the five year electrical total installation check are carried out and evidenced to the Commission for Social Care Inspection by the date set. New Requirement at September 2005. First Aid boxes must be kept sufficiently stocked at all times. New Requirement at September 2005. First aid training must be provided to ensure that there is sufficient appropriately trained staff to ensure that there is at least one first aider available on each shift. Training must be booked by the date set. New Requirement at September 2005. Fire drills must be held regularly and must include all staff. To carry out fire drill instruction on Monday 3 October 2005, recording the names of participants and the outcome. This must be confirmed in writing to the Commission for Social Care Inspection by 9.00am on Tuesday 4th October 2004 (including a planned date/s to carry out a fire drill for any staff not included in this first drill). New Immediate Requirement DS0000020817.V256367.R01.S.doc 03/10/05 31/10/05 07/10/05 31/10/05 03/10/05 Mali Jenkins House Version 5.0 Page 28 at September 2005. 27 OP38 13(4) Falls risk assessments must be reviewed to ensure that all control measures are in place and being followed to reduce the number of falls within the home. New Requirement at October 2005. A risk assessment must be carried out in respect of the home’s cat and control measures must be followed to reduce any risk identified. New Requirement at September 2004. 31/10/05 28 OP38 13(4) 31/10/05 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 To review with each service user their preferred rising and retiring time, to record the outcome and ensure that these are acted upon. New Recommendation at September 2005. The Registered person must ensure that the CSCI is informed when staff are employed on a POVA first and that a comprehensive risk assessment is completed. Staff receive diabetes awareness training 2 3 OP29 OP38 Mali Jenkins House DS0000020817.V256367.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. 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