Inspection on 04/01/07 for Mali Jenkins House

This inspection was carried out on 4th January 2007.

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

Mali Jenkins House 30/08/07

Mali Jenkins House 30/09/05

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 Chris Fuller Unannounced Inspection 4th January 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mali Jenkins House DS0000020817.V324804.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. Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 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) www.bupa.co.uk BUPA Care Homes (Partnerships) Limited 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.V324804.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age above 40 years Date of last inspection 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.V324804.R01.S.doc Version 5.2 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 know the visit would take place. The inspection was made by one Inspector and took place over two days beginning at 9.00am and finishing at 5.00 pm on the Thursday and beginning at 12.00 pm and finishing at 5.00 pm on the Friday, 13 hours in all. The manager had returned a detailed pre inspection information and was able to help with the process of the inspection throughout the two days. Several residents, relatives and members of staff were spoken with during the visit and care practice in the home was observed. A sample of residents files and staff files were seen and other records and documents in the home were read. The Inspector joined residents for lunch and met with the lead chef. The administration of medication was observed and the staff member administering medication was also spoken with. The management and staff team had made very good progress with the statutory requirements from the previous inspection. There was a health and safety issue related to fire safety that remained outstanding however the manager took immediate action to address this issue. A small number of new requirements were made. The inspector would like to thank the residents, management and staff for their hospitality and co-operation throughout the visit. What the service does well: This is a small home where residents and the relatives feel comfortable and made welcome. The home has developed specialist skills and knowledge to provide care for those with Parkinson’s Disease. The premises are pleasant and comfortable being well decorated with good quality soft furnishings. There are suitable aids and adaptations in the home. The meals and mealtimes are pleasant social occasions and the food js well presented with a good choice and variation of dishes available. Residents spoke of the staff being “kind and thoughtful” and “if they can, they would do anything for you”. Relatives said they felt “I prefer the home because it is a small home and so the staff get to know all the people living here”. The management team and staff at the home are dedicated to supporting and enabling residents to achieve their full potential and have good quality lifestyle. Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: At the present time prospective residents do not receive written confirmation that their needs can be met. This matter is outstanding as an issue raised by the previous inspector and so a requirement has been made on this occasion. The Inspector was most concerned to find that after suitable fire training an initial effort to complete regular Fire Drills none had been done since May 2006. This is potentially a serious health and safety risk for those living and working on the premises. An immediate requirement was not made on this occasion because the manager took immediate action to address the matter. However a statutory requirement was made to ensure a regular pattern of fire drills is established. This also highlighted that the management monitoring systems in the home and supervision of staff needs to be improved so that shortfalls in service delivery and care practice are regularly monitored, reviewed and addressed. The manager plans to make application to register as manager of the home having been in post for just over twelvemonths. Some of the policy and procedures need to be updated and guidelines for Protection Of Vulnerable Adults checks Risk Assessments and for making Regulation 37 Notifications provided to staff. Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mali Jenkins House DS0000020817.V324804.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 Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. All residents have their needs assessed prior to moving into the home. The management and staff encourage visits to the home and short stays or trial periods to give the residents an opportunity to ensure the home is suitable to meet their needs. The home is still not however established a formal process to assure residents prior to admission that their assessed needs can be met by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does request and will take into consideration health, nursing assessments and social care and housing assessments of residents needs and these records can be seen on residents files. A large number of residents initially access the service through the respite placement or may do a month trial period. Both of these limited stay arrangements give residents and the Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 10 home an opportunity to check out whether the home is suitable. During this period the home with the agreement of the prospective resident may seek the opinion of other professionals such as community psychiatric nurse. The manager confirmed that the home has a comprehensive assessment format that is completed for all residents prior to their admission to the home. Usually two members of staff from the home, the manager and one other will visit the resident at home or in hospital to introduce themselves, give information about the home and to make the assessment. The manager usually gives verbal confirmation to the applicant, their relatives and or social worker. This was discussed as it had been raised at the previous inspection visit that written assurance must be given to the applicant that the home can meet their needs. The home has produced an attractive brochure all about Mali Jenkins to issue to enquirers and prospective residents. It has colour photos of residents, staff and facilities at the home. It also gives details all of the services and facilities available. Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 Quality in this outcome area is good. Progress has been made to improve staff training and practice in the safe handling and administration of medication within the home and to protect the residents health and well being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that care plans produced and implemented for all of the assessed needs of residents. There had been an issue where the blood sugar levels for one of the residents had not been recorded however this process has been implemented and proven effective. District nurses maintain their own records and they are also asked to sign the homes records. A sample of resident’s files were seen and the care plans were found to be comprehensive and are reviewed monthly and the date documented. There has been an improvement to the storage of care plans and these are kept Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 12 secure and locked in a filing cabinet. A new care plan format has been designed and improved. There is a roll out programme to implement the care plan format in April - June 2007. There will be training for management and staff and all are to attend. The manager felt confident that much of the new format was relevant and meaningful to the needs of residents of Mali Jenkins. At the present time the staff complete daily records three times a day am pm and night time; these records give a continuous record of the residents health and well being and of care provided. There is also a separate record sheet of all health appointments made, attended and treatments or action taken. This provides a quick reference history of the health needs of the resident. It also is a useful monitoring tool that all aspects of a residents health care needs are being reviewed and addressed. One member of staff is delegated to ensure that residents are weighed on a regular basis. Any significant patterns or marked changes are noted and appropriate follow up action taken. The manager confirmed that the home has the appropriate risk assessments for all safe working topics however these were not inspected on the day of inspection. A risk assessment has been provided for the cat in line with the company policy. Following issues relating to administration of medication the manager took measures immediately to ensure an improvement in medication administration to ensure the safety of service users. This has improved practice and reduced the risk identified. There had been a significant change in senior staff and a time lapse of appointment of new staff and their training. The senior staff and management team have all completed the accredited training in the safe handling and administration of medication. Given the wide range of needs of the residents in respect of medication this is administered throughout the day to meet individual prescription instructions and the needs of residents. Where this presents problems with the residents daily routines this would be reviewed with the GP to facilitate choice and preference. Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. Residents preferred interests and activities are encouraged and a programme of events provided by the Activities co-ordinator. Family and friends of residents are welcomed to visit and join in daily routines at the home and outings to the local community and community facilities are promoted. Whenever possible residents are helped to exercise choice and control over their lives. Residents receive a wholesome and appealing balanced diet in pleasant surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The building has a central main lounge and dining area where all residents and staff come together and share meal times and social activities. The furniture arrangements of the room reflect the lifestyle of the home with the dining area taking up a central position and comfortable chairs and sofas being arranged in small groups and leading to the windows overlooking a small patio and garden area. The ethos of the home is centred around a flexible and responsive Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 14 delivery of care with staff remaining vigilant in observing and checking out the changing needs of residents. Residents are encouraged and enabled to retain their independence in all aspects of daily living and staff were heard to check out choices and preferences, make suggestions and give reassurance. The manager states the home has made some improvement to recording daily lifestyle preferences and following a review of each service users preferred rising and retiring time this has been recorded in the outcome section of the care plan and key workers ensure that these are acted upon. The home has a designated activities officer who organises a range of group and individual activities and outings and co-ordinates staff support and resources. The home has 40 hours a week that are given to social activities. There are restrictions on leisure pursuits as all funding has to be raised by staff at the home or donations from residents. Also there is only one approved driver for the transport that is provided and booked through the Parkinson’s Disease Association. Generally staff are obliged to volunteer to assist and do this in their own time, if outings are to go ahead. Residents recognise this and state “The activities and leisure programme is excellent with a lot of hard work put in by staff.” During the inspection the following activities took place; a pat the dog session, a quiz, painting and nail manicure. The activities officer explained there are a range of events such as gentle exercises, speech exercises, Bingo, clothes parties, quizzes, gift parties, mobile library, entertainers, fete and coffee mornings, church services, shopping trips, pub meals, museums and trips out. Relatives of residents are welcomed to visit at the home at any time within social hours. Feedback from relatives confirmed that they always feel as if they are made welcome and generally are offered some refreshment. They would sit with residents in their own rooms or in the main lounge / dining room area. There are also small conservatory rooms where four or five residents may sit or residents meet with their relatives. They did feel there was a good programme of social activities but felt the home would benefit with more contact with the local community and through use of local facilities. The dining area is also used as an activity area for table top activities and and alternative seating area to the easy chairs. At meal times the tables are attractively laid up with tablecloths, placemats and cutlery settings. The menu of the day has been well presented and mounted in a stand on each table. The meals given on the day were those listed in the menus. The Christmas design of menus was very attractive and reflected the Christmas decorations around the room. Menus for lunch time offered a four course meal with a choice of main dish. Breakfast gave a wide range of choice including hot dishes such as eggs, bacon, tomatoes and beans etc. There were four kitchen staff with a head chef, a cook, and two kitchen assistants. The head chef is due to update the intermediate food hygiene qualification and has several years experience working in an range of culinary posts. The kitchen appeared to be well run Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 15 with all equipment in working order, temperature records of fridge freezers and food were up to date and signed. Completion of daily kitchen tasks are allocated and monitored. There was a good range of food stocks, both fresh and frozen. Fresh fruit is put in the dining / lounge area for residents. The head chef and kitchen staff are part of the staff team and will also spend time with the residents to check out their likes and dislikes and preferences and the chef was able to speak in detail about the particular dietary needs of individual residents. Residents said “the food is really good and there is always plenty of it.” Staff were seen to discreetly check out with those that might require assistance and return regularly to anyone that might have difficulties eating. The manager believes the last visit made by the Environmental Health Officer was in 2004. Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Progress has been made through lessons learnt, training and improved systems for the protection of vulnerable adults to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints log appeared to be well maintained with many complaints listed and noted as addressed within appropriate timescales. There had been no complaints recorded during the past inspection year. The relatives stated “We are fully aware of the complaints process and the flow of information is very good.” Residents confirmed that they knew how to make a complaint and felt they could bring any issues to the attention of staff and management and they would be sorted out. There was evidence on file and on the notice board of several cards and letters of appreciation of the care provided with comments stating “We appreciate the friendly and welcoming atmosphere when visiting and the patience and kindness shown to all of the residents.” and “The care and specialist knowledge of the staff has made a great difference and improvement to quality of life.” The manager confirmed there had been no adult protection incidents during the past inspection year. At the time of the inspection all staff (with the Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 17 exception of three) and management had attended an appropriate Adult Abuse / Protection training. Two of the new staff are due to attend training in February and the third staff member who had missed the previous course will join them. Every member of staff is provided with a BUPA Care Services Working Guide on the first day of their employment. Within this is a section relating solely to Adult Abuse, how to recognise it and what to do about it. The manager considers them to be sufficiently prepared to know what action to take in the event of any concerns or incident arising. Adult Protection training should form part of the foundation training for all staff and be regularly updated. Lines of accountability are clear when the Manager is not on duty names and telephone numbers for the manager and more senior company managers are displayed on the staff notice board in the ground floor office. Telephone numbers for Social Care and Housing and Adult Protection Team are also displayed. The home’s Adult Protection Policy and procedure was reviewed in September 2003 and must be updated and reflect the Local Authority guidelines. The manager confirmed the latter are now available in the home. The home does not have a copy of the Department of Health’s ‘No Secrets’ document within the home. The manager confirmed the Whistle Blowing Policy had been updated to state that staff ‘should’ rather than ‘must’ report incidents. The Whistle Blowing Policy has been updated to advise staff as to the role of external agencies in such matters and gives their contact details. The policy on restraint was available in the policy and procedure manual. There has been no training for staff in the use of restraint. 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. Mali Jenkins House DS0000020817.V324804.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 and 26 Quality in this outcome area is good. The home provides clean pleasant surroundings for residents that are well maintained and decorated. Individual rooms of residents reflect their personal interests and backgrounds. A range of facilities including suitable aids and adaptations enable residents to maximise the opportunities for residents to retain their independence skills and abilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises are well maintained and there was evidence of regular repairs and replacements and works completed were detailed in a maintenance record book. The home employs a maintenance worker 22 hours per week and a handyperson 18 hours per week. The home and grounds looked well cared for and homely with an attractive entrance to the building of flowering tubs and Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 19 baskets in January. The car park has marked bays and the area is clean and tidy. Internally the furnishings are mainly traditional colours and patterns with a mix of comfortable furnishings and fabrics. Individual rooms are personalised with many items and ornaments reflecting the resident’s hobbies interests and personal background. There is an ongoing programme of decoration and the majority of the home looked pleasant and seasonal with Christmas decorations hung in the lounge / dining room area. Some carpets need replacing in the small lounge conservatory rooms which provide pleasant seating areas for small groups, residents and their visitors. Some of the residents had raised an issue with the inspector about dim lighting both in the main lounge and in their own rooms. The home use economy light bulbs which gradually increase in light levels over a period of time. Light shades cast low shadows in rooms and give an appearance of dim lighting for those reading or other close work etc. During a tour of the premises it was noted that small lamps with shades are inappropriately placed, are not plugged in or give insufficient light. The manager was asked to review lighting for all residents and this was done promptly. The manager conducted a survey of current residents to check out who if any wished to have additional lighting or changes to their existing lighting. However none wished for any change. The manager states that whilst the design of the building does not lend itself to being very bright the appropriate levels of light are being recorded. Action taken since the previous inspection has been as follows: The clinical waste holder in the toilet has been replaced. The scuffed and marked grab rails and door frames have been decorated. There have been thermostats provided in all bathrooms. It is proposed that a new carpet and new lounge furniture will be provided in spring time with the new budget. The home does not have a record of the last visit made by the Environmental Health Officer. The Head Chef is not aware of a visit in the last two years and the last clean kitchen award was received in 2004. Mali Jenkins House DS0000020817.V324804.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. Progress had been made with a sufficient number of staff employed and on duty to meet the care needs of the residents. Recruitment practices have improved and the home follows agreed protocols for staff employed with a POVA. New systems have been introduced to ensure staff receive a comprehensive induction to the home and needs of the residents and a programme of training in all safe working topics is provided to ensure a competent staff group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has had a big change of management and staff over the last twelvemonths with the previous deputy manager promoted to manager and a previous activities officer promoted to deputy manager. Several senior care staff left and some ancillary staff with seven staff leaving during the past inspection year. This would appear to have stabilised with new staff appointed and early recruitment as vacancies arise. The staff team feel they have got to know each other others strengths and weaknesses where they need to support each other and are beginning to work well together as a team. Staff shift planning has recently been delegated to the deputy manager and generally there are at least four care staff on duty for morning and afternoon shift and Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 21 occasionally five. In addition this there is an activities co-ordinator and the deputy on duty. The manager is supernumerary but continues to be involved in the daily operations of the home. At the present time there are 7 staff with NVQ to level 2. One of these staff has gone on to NVQ level 3. A further 6 members of staff are due to enrol for NVQ level 2 next week. There is a care staff group of eighteen and this should then provide a minimum ratio of 50 trained members of care staff to NVQ level 2 or equivalent. The summary of achievements states that 75 of all staff have a First Aid Ceritificate. The manager states that the home has 35 of staff who are trained to level 2 (two of them with passes at level 3) and have a further 20 who are enrolled to commence on the programme. A selection of staff files were seen, these had improved since the previous inspection and held a front index with dates of documents and references received. There were dividers for clear sections making information and records readily accessible. The manager confirmed that at the time of interview 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 requested and placed on file. Evidence to support this was seen on the staff files. The home continues to employ staff prior to receipt of the CRB reference. The manager ensures that a POVA reference has been received and is clear and requires the applicant to sign a declaration that they do not have any convictions. The manager states this is practice is in line with the POVA protocol agreed between BUPA Care Services and CSCI. All staff employed with a POVA First Check are supervised at all times by a permanent member of staff. However the manager has not completed a risk assessment and forwarded this to the Commission for Social Care Inspection as requested at the previous inspection visit. This was discussed with the manager who agreed to implement this as part of the recruitment procedure. The manager has developed a spreadsheet displaying the training in all safe working practice topics completed by staff during the past inspection year. Staff files also held copies of certificates of training courses completed. Staff commented they felt supported to complete their training and find the learning from courses useful in their daily practice. The following courses have been completed during the past inspection year: Health and Safety, First Aid, Moving and Handling, Infection Control, Basic food hygiene, and all staff completed safe handling and administration of medication. The home follows the TOPPS Induction pack. The provider BUPA has developed an induction pack which is being implemented with the first member of staff and the manager feels this is very thorough and a good preparation for NVQ studies. The manager has developed and delivers training in Parkinson’s Disease. This provides a common base line for all staff employed at the home in their knowledge and understanding of the residents particular needs. Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 22 Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37 and 38 Quality in this outcome area is adequate. The manager has made good progress over the last twelvemonths towards establishing a competent staff team able to meet the needs of the residents. The manager has made good progress with meeting statutory requirements from the previous inspection and demonstrates a will to safeguard the health and well being of residents and provide a good quality of service provision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Wendy Timms was appointed as the home manager in November 2005. Previously she worked at the home for several years as a care worker progressing to senior, then deputy manager. She had some experience as Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 24 acting manger and was present and assisted with the previous inspection visit. The manager does have the Joseph Rowntree foundation certificate in management. She also has the D31 and D32 Assessors Award. The manager has completed the Residential Manager Award and is awaiting confirmation of a pass. As yet an application to register as Manager of the home has not been submitted to the Commission for Social Care Inspection however the manager gave a commitment to apply. The home does have a range of systems for monitoring care practice and health and safety in the home. The manager stated that each member of the management team monitor these are completed on a regular basis however taking the fire drill as an example this does not appear to be happening. The manager was asked to document all internal audits at previous inspections but this was not inspected or brought to the attention of the acting manager at the last inspection. It was discussed on this occasion and priority must be given to establishing a thorough process for quality assurance systems with clear evidence of internal audits dated and signed by the management team and evidence of actions to be taken where there is a short fall in service delivery. The manager has issued questionnaires for feedback and received 8 returns. The manager states that action is taken on suggestions made and feedback given at the residents meeting. The last one held was 20th October 2006. The minutes of the meeting show an open and frank exchange regarding issues that arise for residents and responses from the management. The meeting reports that the local survey were favourable. The manager provided a copy of the Annual operating Plan overview for 2007 outlining the main aims and objectives for the next twelvemonths. A number of these complement the statutory requirements highlighted during inspection such as: to recruit into vacant positions, to provide regular supervision and yearly appraisals for staff to fulfil planned maintenance and to provide new carpets and replace lounge furnishing. The resident’s financial records and safekeeping was assessed. A sample were seen and found to be in good order. Neither the Manager nor provider is the appointee for resident’s; this 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. 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. The manager confirmed that individual items are identified as to whom they belong. The staff files do not have a section for supervision records, staff appraisals and current training and development. The manager explained that it has Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 25 been difficult following the changes in senior staff to fulfil the supervision and staff appraisal arrangements. However it is proposed to delegate some supervisory duties to the management team members. The home employs an administrator 20 hours per week to assist with the home’s administration. The staff files seen were current comprehensive and in good order. The resident’s files were in old files and had no front index sheet or file dividers. Information was on file but difficult to access and would be especially difficult for new or agency staff. The manager gave assurances new files were due to arrive and new formats for recording. There should be considerable improvement in this area at the next inspection. The manager returned the pre inspection questionnaire with comprehensive information of the maintenance and associated record checks with dates of completion. The matters outstanding from previous inspection had been addressed and the majority of checks were up to date or were booked and due in the near future. Emergency lighting was checked by the maintenance person on 18.12.06. There are two agency visits that remain outstanding from the Environmental Health Officer and from the Health and Safety Officer. The Leigionnaire Water check is booked for February 2007 and the Nurse call system is due to be done at the end of January 2007. There continues to be a high number of falls for a small home incurred by residents, which the manager partly attributes to the nature of Parkinson’s Disease, which the majority of residents have. Risk assessments are in place and are regularly reviewed to identify any patterns or trends and action is taken to address these to further minimise any risks. The inspector noted that some of the visits recorded in the accident record involving a visit to A&E at hospital had not been notified to the commission for social care inspection. Also some of the notifications were not held on file as the original copy had been submitted and a copy had not been kept. There was no clear written procedure for notifications or guidance to staff. There is one pet cat 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 been undertaken since the last inspection. A cat potentially poses a tripping hazard in a home however the manager feels that there have been no incidents where this has been the case. Residents spoken with enjoy having the cat around and other events where a dog or a donkey are brought to the home for the pleasure of the residents. There was a serious health and safety matter in respect of Fire Safety identified. The last Fire Drill had been completed in May 2006. Fire Drills had been a requirement at the last inspection and although the designated Fire officer had made an initial effort to meet the standard this had not been maintained. This was compounded by the fact that monitoring systems had proved ineffective and there was no evidence of formal supervision of this Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 26 member of staff. This leaves all living and working in the home vulnerable and at risk. An immediate requirement was not made on this occasion as the manager used her initiative and made immediate arrangements for a fire drill to be completed the following day and records were seen to be improved in detail and content. However it is important that this is procedure is regular and at appropriate intervals. Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 3 2 Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 28 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 OP3 Regulation 14(1)(d) Requirement The registered person and manager must ensure the prospective resident is given written assurance that their needs can be met prior to admission to the home. 3 The Registered person must ensure that a minimum ratio of 50 trained members of care staff to NVQ level 2 or equivalent is achieved. Timescale of May 2004has not been met. The manager must submit an application to CSCI for registration as manager. 31 The Registered Manager must document all internal audits undertaken. Not assessed at September 2005 Timescale of 2005 has not been met. The registered person and the manager must ensure that all staff with supervisory responsibilities receive suitable training in supervision skills. The registered person and the manager must ensure that all DS0000020817.V324804.R01.S.doc Timescale for action 28/02/07 2. OP28 18 31/07/07 3. 4. OP31 OP33 9 24(1) 31/01/07 31/01/07 5. OP36 18(2) 31/03/07 6. OP36 18(2) 31/03/07 Mali Jenkins House Version 5.2 Page 29 7. OP38 13(4) staff receive supervision six times a year and an annual staff appraisal. 36 First Aid boxes must be kept sufficiently stocked at all times. Timescale of September 2005 has not been met. The registered person and the manager must ensure a fire drill is completed at least four times a year at the appropriate intervals and times of day and include all staff.38 The registered person and the manager must ensure that a procedure for making regulation 37 notifications is produced, implemented and displayed for use by all staff. 38 31/01/07 8. OP38 23(4)(e) 08/01/07 9. OP38 37(1) 31/01/07 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. Refer to Standard OP19 OP19 OP29 OP38 Good Practice Recommendations The Registered person should request a visit from the Environmental health officer. Replace carpets in the small lounge conservatory rooms.19 The registered manager should provide a Risk Assessment to the Commission for Social Care Inspection of staff employed with a POVA. Staff receive diabetes awareness training Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 30 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mali Jenkins House DS0000020817.V324804.R01.S.doc Version 5.2 Page 31 - 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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