Inspection on 07/05/08 for Min-Y-Don

This inspection was carried out on 7th May 2008.

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

Min-Y-Don 21/05/07

Min-Y-Don 15/12/05

Min-Y-Don 16/10/05

Min-Y-Don 21/07/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Min-Y-Don Min-y-don 24 Clifton Road Tettenhall Wolverhampton West Midlands WV6 9AP Lead Inspector Sue Woods Key Unannounced Inspection 7th May 2008 09:40 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 Min-Y-Don DS0000064532.V363883.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. Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Min-Y-Don Address Min-y-don 24 Clifton Road Tettenhall Wolverhampton West Midlands WV6 9AP 01902 77 49 50 01902 774 953 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) West Midlands Residential Care Homes Ltd Care Home 26 Category(ies) of Dementia (26), Old age, not falling within any registration, with number other category (26) of places Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st May 2007 Brief Description of the Service: Min-Y-Don home is a large detached, Victorian property set in its own attractive grounds at the end of a private drive. A purpose-built extension has been added to the home. The home, which provides accommodation for 26 people, is within walking distance of Tettenhall village where there is a post office, shops and a variety of other amenities. There are three double bedrooms, and 20 single bedrooms, three bathrooms, one shower, eight WCs, three lounge/dining rooms, a conservatory, laundry, kitchen, staff room and a managers office. There is a large car park and extensive grounds, which include an enclosed garden. The present Registered Individual Mr Hareendran Balasubramaniam (on behalf of West Midlands Residential Care Homes Ltd) has been operating this care home since July 2005. Consultation with people who live at Min-Y-Don has previously taken the form of regular surveys. The new manager of the home is looking to continue with these and is also planning to introduce ‘Resident’s meetings’. Inspection reports about this service can be obtained direct from the provider or are available on our website at www.csci.org.uk Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that people who use this service experience poor quality outcomes. The unannounced key inspection of Min-Y-Don took place on 7th May 2008 between 9.40 am and 5.25 pm. The inspection reviewed all twenty two of the key standards for care homes for older people and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the inspection we, the commission, met with a number of people living at the home and with all staff on duty at the time of the visit. The inspector also handed out surveys for completion by staff and people living at the home. Three were returned. Support for the inspection came from the manager. Four care files were reviewed in detail and extracts were seen from others. Other records referred to within the report were also seen. Prior to the inspection visit the manager completed and returned an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. The AQAA identified areas where the new manager has prioritised her efforts. At the time of this inspection the manager of the home had only been in post for five weeks. As part of this key inspection we asked an additional set of questions (a thematic probe) to three people who live at the home, three staff members and the manager in relation to ‘Safeguarding processes. What the service does well: People who live at Min-Y-Don told us that they liked living there. One person said ‘It is my home from home’. People also speak highly of the staff. One person commented that ‘Staff are nice, kind and friendly’. Someone else said ‘Staff are lovely and do a good job’. Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 6 The home offers a good range of activities and the staff work hard to ensure that everyone has the opportunity to take part in them. What has improved since the last inspection? What they could do better: During this inspection major concerns were raised in relation to the home’s recruitment practices and the lack of knowledge and training for staff in relation to areas of abuse. Training must improve to ensure that staff are aware of what constitutes abuse and manager must identify when it is appropriate to refer to the multi agency procedures for safeguarding people. Incident recording is poor and staff have not received support or training to manage behaviours that challenge. As a result people may get hurt or not be properly protected. Risk assessments and care plans can be improved to ensure that the manager and staff on duty are aware of all of peoples care and support needs and that all risks to an individual are assessed and actions identified to reduce or eliminate them. Staffing levels continue to be problematic within the home and although minimum staffing levels are now in place the manager must ensure that these are safe and take into account staff’s unpaid breaks. Staff training has not taken place as it should although the manager is working at making sure all staff receive at least all mandatory training. Policies and procedures were not available to support the manager’s practice at all times. This may have left people vulnerable, as procedures have not been followed especially in relation to the pre employment screening of staff. Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 7 Information about the home should be updated to reflect what the home can and cannot offer. 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. Min-Y-Don DS0000064532.V363883.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 Min-Y-Don DS0000064532.V363883.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): Standards 1, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at Min-Y-Don have their basic care needs assessed before they move in to the home so that staff are able to meet those needs when they arrive however information provided by the home to people before they move in may not accurately reflect the service offered meaning they may make the wrong choice about whether the home is right for them. EVIDENCE: As part of the inspection we looked at the assessment of the last person to move into the home and had the opportunity to speak with the person about the process. An assessment of need was seen to have been completed by the manager prior to the person’s admission although it was not very detailed due to the lack of information available to the manager. Other files seen also Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 10 contained initial assessments carried out by the home and these too only offered basic information. Two of the four files seen contained an assessment that had been carried out by a social care professional and the manager stated that information contained within one of these was inaccurate and hence it did not reflect the assessment carried out by the manager. The homes Statement of Purpose and Service User Guide contained information that required updating. For example current management arrangements were not identified correctly. One person said that she didn’t know enough about the home before she moved in and has since decided that it was not for her. The home does not offer intermediate care. Min-Y-Don DS0000064532.V363883.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): Standard 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who live at Min-Y-Don do not all have a care plan that accurately reflects their individual needs and some risk assessments do not identify safe support for people. As a result people may not their care and support needs met or managed safely. EVIDENCE: Three of the four care files reviewed contained a care plan. The manager stated that she did not complete care plans for people until they had lived at the home for about eight weeks. This arrangement may mean that in the early days of someone’s stay at the home the staff team do not know how a person’s care and support needs should be met. This was evident at the time of the inspection when the manager and the staff team both had information about a person that had not been shared. Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 12 Care plans that were available were basic although the manager is looking to reintroduce a previous format that was much more detailed describing care needs and how they are to be met. Given that a high number of people have dementia this additional information will be valuable to support consistency within the staff team. Risk assessments were in place for three of the four people whose files were seen. Assessments identified risks although did not always offer actions to reduce those risks. For example one person who had identified behaviours that make her and others vulnerable had no reference of how staff should manage this in her plan. In addition to this staff have not had training to manage challenging behaviours. This suggests that staff cannot always meet people care needs safely. Daily records show that some behaviours have occurred but not been recorded as incidents or referred to safeguarding adults teams if appropriate. The home works with health care professionals who visit the home as required. Records show outcomes of the visits and monitoring records show that staff observe any changes in people’s wellbeing. Medication arrangements within the home were seen to be in need of review and the manager has already started this process. The home is awaiting the arrival of a new trolley to store medication as the lock is broken on the old one. When this arrives secure storage will be made available for controlled medication kept on the premises. Recording was inadequate. Times for the administration of medication were recorded as morning, noon and night. Some people’s records suggested that they very regularly do not receive their prescribed medication as they were either asleep or ‘other’ (which is not specified). Confusion at the time of the inspection as to when a medication was not administered proves that the system is potentially making people vulnerable. The manager reported that a new chemist has been requested to support the home given additional problems that the manager detailed in relation to the receipt of medication into the home. Staff, on the day of the inspection were seen to be polite and courteous to people they were supporting. People were able to spend time in their rooms if they chose to. Min-Y-Don DS0000064532.V363883.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): Standards 12, 13, 14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Min-Y-Don enjoy opportunities to lead full and ‘active’ lives and people’s individual lifestyles are supported meaning they can enjoy a good quality of life. People enjoy a varied diet according to their assessed needs and individual choice. EVIDENCE: On the day of the inspection people who live at Min-Y-Don were enjoying a range of activities. In the morning two groups of people were making birthday cards for a lady whose birthday it was. The sessions were seen to be relaxed and staff offered gentle encouragement and support for the people taking part. One staff member started an impromptu singsong and others joined in. Later in the morning and throughout the afternoon almost everyone was sitting outside enjoying the sunshine and taking part in Karaoke and then bingo. One person requested a sherry as she said it ‘didn’t feel right to sit outside without one.’ Staff supported this request demonstrating the effort that is made to meet the requests of people living at the home. Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 14 One person told us that although she didn’t like to join in group activities she enjoyed watching them and she was never pressured to take part. People were also seen reading the newspaper and watching television. The home has an activities schedule but staff said that they also do impromptu activities depending on the weather and how people are feeling on the day. Staff felt that activities have improved over the last six moths. The manager has introduced monitoring records that demonstrate that there are numerous activities on offer every day. Family contact is encouraged and supported. One person said she would like to keep in touch with some people she hasn’t seen for many years. The manager said that she would support this person to write to her friends. The manager recognised that often making choices is difficult for some people living at the home. Records show peoples likes and dislikes and goals are identified and monitored. Some people who spoke to us said that they could get up and go to bed when they like. The menu identifies an alternative each day. On the day of the inspection the cook had prepared a buffet tea for everyone to celebrate one person’s birthday. Likes and dislikes, in relation to foods, are recorded. Different dietary needs are catered for. Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 15 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): Standard 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives have access to a complaints procedure, which enables their views to be listened to however a lack of staff awareness and training in certain areas and unsafe recruitment practices mean that people may be vulnerable to abuse. EVIDENCE: The home has a complaints procedure that the manager said was last updated in 2004. Information did not reflect current arrangements for managing complaints but did identify an open process that encourages people to speak out. People who spoke with the inspector said that they would talk to the manager if they had a problem. The manager is planning to introduce ‘residents meetings’ to discuss issues and suggestions that people who live at the home might have. She also spends time with people in order that they may confide in her more informally. Although the manager recently reported an allegation of abuse to the local safeguarding adults team and took appropriate action to safeguard the individual in the future the home does not currently have a safeguarding adults policy and the Abuse policy is out of date. Staff reflected this when only one Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 16 person said that they had seen the policy and read it. In addition a requirement was made at the time of the last inspection that staff attend training in safeguarding (adult protection) procedures and to date this has not happened. Staff have also not received various mandatory training courses in safe working practices and in particular managing people with challenging behaviours as there is recorded evidence, supported by statements by the manager and the staff team that some people hit out at staff and other people who live at the home. Such incidents are currently only recorded briefly in the daily notes and not recorded or responded to as incidents. Current recruitment practices are also placing people at risk as pre appointment safety checks are not in place before people start work. See staffing section for details and requirement. Two out of three people living at the home, when asked said that they did know who to talk to if they didn’t feel safe or were frightened. Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 17 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): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Min-Y-Don is clean and well maintained. Recent and planned improvements will provide the people who live there with a comfortable and safe place to live. EVIDENCE: Since the appointment of the manager five weeks ago the home has been redecorated in a number of communal areas and in addition new flooring has been fitted to bedrooms. The manager has further plans for redecoration and improvement. For example the manager is awaiting a quote to turn a downstairs bathroom into a walk in shower room. She has also arranged for a raised flowerbed to be built in the garden as some people have expressed a wish to do some gardening. At the time of the inspection one person went into the garden and bent down to touch the flowers that have been purchased Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 18 ready to be planted. This suggests that this new facility will be enjoyed by the people living at the home. The AQAA suggests redecoration has taken place and that cleaning rotas have been implemented. These rotas were in operation at the time of the inspection. Staff felt that they were helpful and were happy to work with them. The standard of cleanliness at the time of the inspection was good. The kitchen was in the process of redecoration and having access to a new storage room. Cleaning products currently seen on a low shelf in the kitchen can then be stored securely. Records of kitchen cleaning and temperature checks for the fridge and freezer were being well maintained. All areas of the home were seen to be bright and airy. The manager is looking at risk assessing the ramps into the gardens and the small step out into the garden to ensure that everyone can safely access this area. Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 19 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): Standards 27,28,29 and 30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People who use the service are supported by a committed staff team however the lack of appropriate training and the homes poor recruitment procedures are potentially placing people at risk of harm or abuse. EVIDENCE: There is always three care staff and one senior member of staff on each shift during the day. At night there are two waking night staff. In addition there is a cook, a cleaner and a laundry worker on duty each day. Although the manager stated that staffing levels would never fall below these numbers there is evidence that the care staffing levels are still not adequate to meet the assessed needs of the people who live at the home. The majority of staff thought current staffing levels were safe but not all agreed. Examples to suggest that more staff are needed include; three people needing two to one support, a number of people attempt to leave the building if not supervised at all times, staff having to interrupt the giving of persona care to attend to other peoples needs and people having to wait for their meals as they require help to eat. The manager was aware of the need to review staffing levels and would like to see senior staff working alongside four carers. This would also assist with the administering of medication that is also quite time consuming. Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 20 At the time of the inspection there were three females staff on duty and one male. A review of staff files for new starters identified that two of the staff working at the time of the inspection were doing so before the manager had received their CRB disclosures. The manager stated that she was told this was acceptable practice. She was not familiar with the POVA First process and could confirm that no one had received a check against this list prior to their employment. The inspector saw three staff files. Of the two new staff appointed after the manager started work at the home, one had two references but there was no evidence that the other person had provided any. The manager was confident that one reference had been received but she couldn’t find it. She had sent off for a second reference but to date it had not been returned. The manager reported that there were currently no training and development plans for the staff team but she is prioritising this area for immediate improvement. Staff reported that since the new manager had arrived they had either been enrolled on NVQ or had secured first aid training. The manager also stated that she is a trainer for subjects such as manual handling and has personally delivered this training to the new staff. Other training is planned. Two dates have been secured for adult protection training in the near future. The manager is also liaising with a training provider to arrange ‘dementia’ training. This will be a ten-week course. To date staff have not received training to support people who have challenging and complex behaviours and given there are regular incidents this should now be addressed as a priority. People who live at Min-Y-Don speak highly of the staff. One person commented that ‘Staff are nice, kind and friendly’. Someone else said ‘Staff are lovely and do a good job’ Three people said staff are very busy. Staff told us that they enjoy working at the home. They all spoke positively of the impact that the new manager has had and how supportive she is. One person said the home was ‘Fantastic since Jo has been here’ When asked what they do well staff thought that the food and the care was good. Staff felt that unpaid breaks were an issue and that wages and staffing levels could be improved. One staff member said that ‘overall it is a nice place to work’ Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 21 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): Standard 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recent management arrangements have improved the overall quality of life for people living at Min-Y-Don and the health and safety and welfare of people living at the home and the staff team is now better promoted however a combination of lack of policies and procedures, poor staff training opportunities and lack of knowledge in key areas relating to protecting vulnerable people have all put people at risk of harm over the last twelve months. EVIDENCE: At the time of this inspection the manager of the home had only been in post five weeks. In that time she had familiarised herself with outstanding Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 22 requirements made by CSCI and has taken steps to address most of them. The quality rating for this outcome group reflects this contribution. The manager has a care qualification at level 3 and will be enrolling on the Registered Managers Award in September. She is a trainer for mandatory subjects relating to care and safe working practices and has experience of both residential and community based services for older people. Staff feel confident with the new mangers abilities and are already reflecting positively on her achievements within the short amount of time that she has managed the home. The manager reported that she is in the process of submitting her application for registration with CSCI. The manager reports no financial restraints in order to make improvements to the home and feels well supported by the proprietor. At the time of the inspection however the manager was operating without policies and procedures and some guidance that she had been given was not accurate yet she had followed it. Since the time of the last inspection it was reported that there have been a number of management changes leading to delays in requirements made by CSCI being met. This has left people who live at the home potentially vulnerable and staff ill equipped to do their job. The manager said that the home only looks after money for people who live at the home if required. They have no other involvement. She said that the recording system is good showing all monies in and out. She felt that the system safeguarded people’s finances. Records were not seen on the day of the inspection. Again there was no policy to review to support procedures. Health and safety checks were seen to be up to date. The manager was advised to review the fire risk assessment to ensure it covered areas such as evacuation. The manager was reminded not to prop open fire doors that are self-closing in an emergency. Water temperatures were tested by the manager at the time of the inspection and found to be only ‘hand warm’. She stated that she regularly checks water temperatures and they are usually adequate. The manager will investigate this issue and also ensure that water temperature are checked and recorded every time a staff member runs a bath for someone. Given that water temperatures were an issue made at the time of the last inspection by CSCI this will remain as a requirement. Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 23 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 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 1 10 3 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 1 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 24 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 15 Requirement The home must produce a plan of care from robust initial needs assessments for all people living at the home in order to ensure that peoples care and support needs can be identified and met. Timescale for action 21/07/08 2 OP7 13 (5) 3 OP7 13 (4) (b)(c) 13 (5) 13 (6) 4 OP18 The home must establish safe 21/07/08 systems for moving and handling service users. This is to ensure that people are moved comfortably, as independently as possible and safely minimizing risks of injury to service users and the staff team. Unnecessary risks are identified 21/07/08 and minimized through use of risk assessments. This is to ensure that as far as is possible people remain safe. Written guidelines must be in 16/06/08 place for each individual with complex behaviours living at the home that reflects current safe and best practice. Staff must receive training to manage behaviour that challenges the service and put people at risk of DS0000064532.V363883.R01.S.doc Version 5.2 Page 25 Min-Y-Don 5 OP38 18 harm. This is to keep both themselves and people living at the home as safe as possible using consistent and appropriate techniques that promote the wellbeing of the person challenging the service. Staff must receive mandatory training in respect of Fire Safety Health and safety First aid Food hygiene Infection Control And Moving and handling – In order to ensure the safety of people using the service and protect them from harm. (Previous timescale of 15/08/07 not met). 18/08/08 6 OP18 13 (6) Managers and staff working at all 18/08/08 levels must receive training in adult protection issues and have a policy and procedures available to follow and reference at all times. This is to ensure that any abuse is noticed and referred to the appropriate agency for investigation. It is also to protect the people living in the care home from harm. (Previous timescale of 31/07/07 not met). The Registered Provider must assess and identify safe staffing levels for the home and implement these. This is to ensure that there are sufficient staff on duty at all times (including when staff are having an unpaid break) to ensure that the care and support needs of DS0000064532.V363883.R01.S.doc 7 OP27 18 16/06/08 Min-Y-Don Version 5.2 Page 26 everyone living at the home can be safely met at all times. 8 OP9 13 (2) 9 OP37 12 (1) 10 OP38 23 (2)(j) 11 OP29 19(4, 5) Schedule 2 The home must implement safe systems for the administering and recording of medication for people living at the home and seek medical intervention when people regularly do not take medication that is prescribed for them. This is to ensure that people receive the medication they need and the home can demonstrate that they can administer it safely and as and when required. Policies and procedures must be in place to support all practices within the home. This is to ensure that staff work safely and consistently within written guidelines for good practice and take appropriate action following incidents. Action must be taken to ensure a consistent supply of hot water. This is to ensure that people using the service enjoy a bath whenever they chose at a safe temperature. (Previous timescale for this requirements 01/07/07 not met) Recruitment procedures must ensure that all pre employment screening has been carried out on staff before they work unsupervised within the home or service users may be at risk of harm or abuse. 02/06/08 28/07/08 28/07/08 12/05/08 Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 27 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 OP1 Good Practice Recommendations Minor amendments should be made the Statement of Purpose and Service User Guide to ensure both documents are an accurate reflection of the service provided and meets the requirements of the Care Homes Regulations 2001, as amended. This will ensure anyone interested in moving in to the home will have accurate information to base his or her decision upon. It is recommended that the Care Manager complete the Dementia Care Mapping course as part of the home’s quality assurance system and that staff receive training to support people with dementia using current best practice guidelines. This is to ensure that people living at the home receive the best quality of care. It is recommended that quality assurance systems in the home should be re introduced. This should include publishing results to people using the service, and their relatives’ questionnaires and producing an action plan for development. The Care Manager should develop systems for determining the views of people using the service with Dementia who are unable to verbalise their needs. This is to ensure that he home is providing care and support that is based around individual needs and preferences. 2. OP33 3. OP33 Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Min-Y-Don DS0000064532.V363883.R01.S.doc Version 5.2 Page 29 - 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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