Inspection on 09/05/06 for Ormidale House

This inspection was carried out on 9th May 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 44 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ormidale House 25/01/08

Ormidale House 24/01/07

Ormidale House 13/12/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Ormidale House 41 Woodgreen Road Wednesbury West Midlands WS10 9QS Lead Inspector Deborah Sharman Key Unannounced Inspection 9th May 2006 08:30 Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 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 Ormidale House DS0000065596.V296867.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ormidale House Address 41 Woodgreen Road Wednesbury West Midlands WS10 9QS 0121 556 0567 0121 556 0567 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) Chuhan Limited Brian Turney Care Home 11 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (2), Physical disability (4) of places Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The outstanding requirements from previous inspections are addressed within stated timescales as detailed in the action plan provided by Mrs Freeman, signed by her and dated 10th October 2005. 13th December 2005 Date of last inspection Brief Description of the Service: Ormidale House is a large detached house on the main road from Wednesbury to Walsall. It is close to local transport network and there are a number of local shops and pubs located close by. There are parking facilities for a limited number of cars at the front of building. Bedrooms are located on the ground and 1st floor. There is a bathroom on the ground floor and a shower room on the 1st floor. There is no lift available but a stair lift has been fitted. A smoke room is provided for service users separate to other facilities. Lounge and dining facilities are sited within one main area and the dining area has views of the rear of the property. To the side of the property there is an outbuilding, which is currently used as storage space. Access to the garden is limited for service users with mobility problems. Weekly fees range from £370.00 to £598.00 per service user. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection meaning that all the key National Minimum Standards were inspected. This inspection is the first of the new inspection period 2006 – 2007 and was unannounced meaning that no one associated with the home received prior notification and were therefore unable to prepare. The inspection was carried out by one Inspector who arrived at 8.30 am and finished at 7.00pm. Both the Manager and proprietor supported the Inspection. Service users provided the Inspector with written feedback about the home and the Inspector met as a group with those service users who had requested to do so. The service users were informed that if they wished to speak privately to the inspector after they would be able to do so. No one chose to. The Inspector was also able to speak briefly to other service users during a tour of the environment. The Inspector was also able to interview a staff member in relation to the core Standards to verify and cross reference evidence. The Inspector was able in addition to observe a staff member administer medication to service users. Progress towards meeting requirements issued previously to bring about improvement was also assessed. A range of documentation was assessed to verify systems in place to protect the health and safety of service users. Some aspects of care provided to several service users were case tracked through a mixture of discussion with service users and through assessing care records to inform the Inspector of outcomes for service users. When planning this inspection areas that were of little concern to the Inspector from the outcomes of the previous inspection and from additional comments received from service users were not wholly reassessed. For example medication management was previously satisfactory but it was noted that at the last inspection administration had not been observed. Therefore only medication administration was assessed on this occasion. Likewise meals were praised at the last inspection and in comments at this inspection, therefore this aspect of service provision was not reassessed. Nutritional assessment and service users weights were of concern previously and were therefore reassessed at this inspection. What the service does well: The Manager and new owner have developed a good working relationship. The new owner of the home is keen to improve the environment and service users are appreciating the improvements made. The premises are fresh smelling (with the exception of the smoking room which was heavy with smoke). Maintenance documents to demonstrate that the premises and equipment are regularly serviced and maintained were up to date providing reassurance that Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 6 risk is minimised. Service users spoken to said that they are happy at the home and like the other residents and staff. They all said that they feel safe. Service users spoken to are independent and confirmed that they all manage their own personal care and their privacy throughout is respected by staff. Service users who are in a relationship, also said that their privacy is fully respected. Arrangements to manage service users finances have considerably improved and are now well managed and offer service users better financial protection. The observation of the administration of medication provided no concerns as administration protocols were observed. Some service users are supported to attend college one evening per week. All service users in their written feedback to the inspector and in discussion praised the meals provided. What has improved since the last inspection? What they could do better: A disproportionate number of improvements remain outstanding. Staff within the home provide a traditional sedentary model of care which is engrained into its culture and the Manager is finding it difficult to change this. Improvements in training, supervision, the management of staff performance, the introduction of robust quality assurance processes, improved attendance at staff meetings, further increase in staffing levels to release the manager to fully manage the home are all required to support and underpin the process of change in order to better meet the needs of service users. The needs of service users must direct and focus the change process. The Manager is reluctant to delegate, preferring to carry out care tasks himself, sometimes returning to the home on his day off to do so. Delegated tasks are often not completed fully or properly and this is further undermining his confidence to delegate. However the Manager must be clear, that it is his role to monitor and review staff performance, taking action where necessary to support and improve any gaps identified in skill, knowledge and performance. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 7 Improved management systems will assure service users that the home is effectively run for their benefit. In addition it became clear throughout the inspection process that some significant adult protection issues over a lengthy period of time have not been reported to the Commission for Social care Inspection (CSCI). This does not reassure regulators that the home has an open and transparent culture, nor that service users are safe. Health outcomes for service users remain poor and this is hindered by poor record keeping. An immediate requirement was issued at this inspection following the continued weight loss of one service user where in spite of previous explicit requirement for improvement no action has been taken to assess and support this service users health. The Manager must obtain more regular pharmacy support visits to the home. This helps the home to ensure it is following best and safe practice with respect to the management of medication minimising risk to service users. Good risk assessments identify hazards, levels of risk and methods for risk control. Risk assessments are unsatisfactory compromising the safety of service users and staff and the need for training to be provided to both the Manager and staff was discussed. Some service users have contact with their families but not all and this situation has been accepted with the assessed needs of service users and families not known and the interests of service users not having been promoted. Service users do not have sufficient access to the community and activity within the home is minimal, institutional and does not correspond fully with service users goals and aspirations leaving some service users unfulfilled, inactive and not attaining their aspirations. 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. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home cannot evidence that it has followed good practice protocols for the admission of current service users to the home. This does not reassure prospective service users that the home obtains sufficient information to ensure that their individual aspirations and needs are assessed, known and met. Performance is therefore poor. EVIDENCE: There have been no recent admissions to Ormidale House. There are no service user assessments for existing service users completed pre admission by placing Social Workers available on the premises and it is difficult therefore to case track and form a judgement about the appropriateness of the placement and whether identified needs have been included in care plans. Discussion with the Manager however indicates that historical information has recently come to light about one service user during adult protection processes that he had not been aware of and which would have raised doubt about the wisdom of admitting this service user to the home. Social Services are aware of the recent individual concerns. The Manager has carried out more recent assessments of service users living at the home. Since the last inspection all current service users have been informed in writing that the home can meet their needs. Service users written feedback about the experience of moving into Ormidale House is mixed. Predominantly it is positive with 4 service users indicating that they were asked if they wanted to move into Ormidale House and that they were also provided with sufficient information to make this Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 10 decision. Two service users were unsure and one said that they were not asked and were not provided with sufficient information to make this decision. The Statement of Purpose, a document that provides potential service users and relatives with information about the home, has been improved since the last inspection. Service user guides have also since been issued to all service users but the information needs some minor updating. The Manager is aware of how to improve the assessment and admission process for future prospective service users when a vacancy arises. The home is currently fully occupied. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Care planning systems do not sufficiently guide staff to be aware of service users assessed and changing needs generally or in relation to health, risk and decision-making. Staff not to have read care plans or risk assessments abd are therefore not able to assist or support service users to take risks or move to more independent living. EVIDENCE: Service users interviewed had very clear aspirations for the future. These are not included in care plans and as such are not person centred. The Manager imparted information about an individuals’ circumstances which he felt made their aspirations unrealistic. Care plans must however set achievable goals as defined by service users. Care plans continue not to address all of service users need e.g. health, medication, financial arrangements and decisionmaking. Written comments from service users to the Inspector said that they are ‘usually’ able to make decisions about what they do each day, but discussion with service users showed that their preferred activities are not available to them. Lack of care planning about decision making for less able service users compromises how staff enable them to make decisions. Discussion with a staff Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 12 member showed that the optician had visited the home and that support had been given to facilitate the testing of a service users eyes. However through further discussion the staff member acknowledged that it had been accepted that service users had had to have their eyes tested and choice had not been given on the day. It was also felt that service users who attend day centre are also not able to choose to stay at home on occasions rather than go to day centre. Discussion with a staff member showed that s/he had not read care plans and had not been supported to be aware of the content of care plans. S/he was not able to fully describe service users needs or how those needs were to be met by staff. Care notes for one able service user who can make a cup of tea independently state ‘X was allowed to make a cup of tea’. This does not demonstrate an empowering culture where staff are aware of service users needs and abilities. A staff member was aware of some safety restrictions that one service user is subject to, but was not aware of the reasons for this. Not understanding the rationale for action may protect confidentiality but may also result in staff making an error in judgement when faced with a situation that requires a decision. Other agency professionals have been involved in meetings where there have been particular significant concerns and situations but multi disciplinary review of care meetings are not taking place for other service users. Poor risk assessments are in place for service users which are very limited. Where significant risk has been identified and where external agencies are involved as a result, Social Services have provided multidisciplinary and detailed risk assessments. Risk assessments undertaken by the Manager however consist of a single sentence hazard statement. A previous requirement to carry out a specific risk assessment in relation to a bedroom window, seeking the advice of Environmental Health has not been complied with leaving the affected service user at potential risk. There is no risk assessment in place for a service user case tracked who smokes leaving the potential of fire. This has highlighted the need for the Manager to undertake appropriate risk assessment training. A staff member spoken to was aware that risk is managed through ‘risk assessment’ but was not able to give any examples of how s /he is expected to minimise risk. Risk assessment awareness training is also therefore required for the staff group. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Service users are not supported to take part in appropriate activities in accordance with assessed need and wishes in the local community. The home does not proactively support most service users to maintain family links and any restrictions that may exist that deny this are not known. Some rights are being adhered to but others such as the right to vote and maintain nutritional health have been denied. The outcome is generally poor. EVIDENCE: Activity plans are not in place for individual service users in accordance with assessed need and preference. Activity is largely insular to the home e.g. karaoke nights have been established on a Saturday night and fish and chip nights on a Friday which service users enjoy. There is however little social inclusion for most service users over and above attendance at day centre and attendance at night school once per week. One service user is now ‘working’ in the kitchen of a day centre on work experience for 2 days per week. This is a valuable development since the last inspection and she clearly is enjoying this. The provision of activities generally is however traditional. Since the last inspection weekly food shopping trips for some service users has stopped as Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 14 food orders are now being made via the Internet. The impact of this on service users had not been considered. The method of recording activity outcomes for service users does not provide the manager with a clear monitoring tool. The Inspector case tracked activities undertaken by one independent service user on the previous 4 Sundays. Records indicated that each Sunday had been the same for this service user. She had ‘listened to music’, ‘eaten her meals’ and ‘relaxed’. This is not sufficient and verifies verbal evidence given to the Inspector by this service user. In discussion service users had plenty of ideas about where they would like to go. This ranged from cinema, theatre, pub lunches ‘more often than once in a blue moon’ and to an art gallery. They explained that there is a trip to the pub on a Monday night but this is for men only. Female service users spoken to appear to enjoy having time at home on a Monday night without the men but were keen to have more outlets for visits themselves. A staff member said that service users ‘just stop at home’ and ‘don’t have the same choices as me’. Service users, staff and the manager all confirmed that service users had not been given the opportunity to vote in the local elections the week before this inspection. Service users said they had been aware it was Election Day and had wanted to vote but nobody had asked them about this. This had been a previous requirement. The Manager said that postal voting cards had not arrived but he had not been sufficiently proactive in following this up. Care plans do not address all services users need for contact with family. Therefore the assumption that ‘X has no contact with family’ because that’s the way it has always been has been accepted without question. This is an area that could be addressed if regular review meetings were being held. Established patterns of contact with family for some service users is however being maintained, except where restricted following multidisciplinary decision based on known risk factors. Service users confirmed to the Inspector that they are able to make and receive calls in private on the office phone but a service user previous request to have her own phone in her bedroom has not been met. Service users said that they are able to make decisions about bed and rising times and that ‘there are no rules, you can do what you like’. They also said that their mail is given to them unopened by staff but support to read it is given when required. This is good practice. Service users unanimously said that their privacy is respected including service users who are in a relationship. This is now proactively supported by the provision of new bedroom door locks and the provision of keys to service users who are very pleased with this improvement. The liberties of two service users are currently being restricted as a result of multidisciplinary decision making based upon recent incident and risk management. Rules on smoking, alcohol and drugs are now outlined in the service user contract which is an improvement since the last inspection. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 15 Service users all spoke highly and very enthusiastically about meals. They said that they enjoy their meals and have sufficient portions and choice. Service users are consulted prior to the meal and they indicate their choice from the menu which is recorded and provided. They indicated that they are sometimes not always allowed to eat between meals but the Manager said that these service users hold snacks in their rooms. Service users did however express the wish to be more involved in the provision of meals, explaining that they would like to develop their cooking skills. A requirement was made as a result of inspection in July 2005 as one service user was found to have lost a stone in weight between September 2004 and July 2005. The same service user was case tracked at this inspection particularly with respect to weight, food intake and nutrition assessment. This service user to have lost one stone and one pound in three weeks. This is in addition to previous losses in weight. The senior staff member who took and recorded the weights wrongly recorded his weight to be ‘stable’ following this significant weight loss. No further action was taken, this was not noted as a concern, the manager was not informed, the manager has not audited or monitored weight records, medical advice has not been sought, the care plan has not been amended, there is no knowledge of what this service user’s safe weight range is, nutritional risk assessments were not available at this inspection. New blank nutritional risk assessment proformas were available but the Manager said these have not been completed. Nutritional risk assessments seen previously were not present. The level of nutritional risk is therefore not known to the home. The outcome demonstrates a lack of understanding of the purpose of taking service users weights, lack of accountability and a failure to respond to this service user’s changing need as well as a failure to comply with regulated requirement. There was no recognition that there may be underlying health problems that require medical investigation. Food intake records for the service user show him to have refused 7 meals in the past month. Some of these records indicate that he ‘refused to get up’ indicating this as the reason for the non provision of breakfast. There was no evidence that he had been encouraged to eat by offering or providing breakfast in his room. The Manager indicated that the purchase of new scales may account for the disparity in weights but there is no evidence of this and action has not been taken to ensure or review the accuracy of weights being taken. Staff have not been provided with training in nutrition awareness. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Detailed information with regards the provision of personal care is available but is not accessed by staff. The privacy and dignity of service users is considered and assured during the provision of personal care and outcomes are generally good, however service users health needs are not being fully met. Medication is generally well managed. The overall outcome therefore is poor due to the significance of health ommissions and poor record keeping. EVIDENCE: Care plans provide detailed information about how personal care is to be provided. A staff member spoken to was able to describe a service users personal care needs. But it was evident that needs other than these were not known. Staff are not reading care plans. Discussion with three service users however showed that they were all happy with arrangements for personal care. A staff member was able to explain how she considers privacy and dignity during the provision of personal care. Service users are well dressed and are clean. Their appearance is individual reflecting their personalities. Care plans continue to suffer from a lack of goals in relation to health management and health screening. Care plans are not accessible to staff and discussion with a staff member showed her to have an insufficient knowledge of service users health needs and what steps the home takes to ensure that service users health is maintained and promoted. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 17 Record keeping in relation to health outcomes continues to be poor. The optician had visited the home and two service users told the inspector they are going to have new glasses. This appointment and outcomes is not evidenced. The Manager said he had arranged hearing tests which had been carried out with it being recommended that one service user fund an expensive hearing aid. This is not necessary and does not maintain service users rights to NHS treatment. The appointment is also not evidenced. An audiology appointment due on the day of inspection was cancelled as a result of the inspection. However, the inspection did not unduly impact upon staff time. There should be sufficient staffing to ensure service continuity in the event of the unexpected. One service user said she had not been to the dentist since admission. There are no records to evidence dental visits for another service user. A visit to the psychiatrist was not evidenced in records. The advice of the psychiatrist according to the Manager who accompanied the service user to the appointment, was quite specific and would, as not recorded, be lost information. Service users also commented that the GP sometimes visits people in the communal lounge. They were aware that this is not right as it does not protect privacy and confidentiality. Staff must ensure that service users are seen in private by professional visitors unless there is good reason not to. Systems are not in place to adequately assess or meet service users changing nutritional health needs. The Management of medication has been satisfactory previously. The administration of medication was observed to be carried out in a manner that protects service users from the risk of error. The home now has on file recorded permission to administer medication to service users. This is a recent improvement but medication is not included in plans of care. The medication policy continues to require adjustment to reflect practice in relation to the transportation of medication. It was of concern that the home has not received any quarterly support visits from the supplying pharmacist in 2006. Records were also not available on the premises to evidence any prior visits. This must be addressed without delay. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Steps are now being taken to safeguard service users and others where risk has been identified and where allegations have been made. Systems are not in place to sufficiently support all service users to raise concerns or complaints. Staff are not adequately guided either to manage behaviours that challenge and the potential for harm remains as a result. The financial interests of service users are now safeguarded by an improvement in systems. EVIDENCE: Ormidale House has a complaints policy but no progress has been made toward developing this into a format suitable for service users. There is no evidence that service users have been supported in other ways to understand how to make a complaint should they need to. In discussion with three service users, all said that they had no complaints. In written response to CSCI prior to this inspection 5 service users said that they do know how to complain but two did not. A complaint log is available that details one complaint made in September 2005 that had not been substantiated. The investigation process that lead to this conclusion is not detailed in the record keeping. Service users and a staff member spoken to all felt that service users are safe at Ormidale House. National guidance has been obtained and the homes policy on physical intervention has been reviewed with reference to recently obtained national guidance. Allegations affecting both the safety of service users and others have been made 18 and 6 months ago. These have been made known to Social Services by the home and multidisciplinary panels have been held to agree strategy and risk management following recent the mast allegation. Action was not taken to Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 19 safeguard the service user following a similar incident 18 months ago. CSCI has not been informed on either occasion as is the homes regulatory duty. This information has not been made known to CSCI at previous inspections. Behaviour plans are in place for some service users to support staff to manage behaviour that challenges. Guidance on how to safety intervene is not known to staff. A behaviour plan is not in place for a service user who is known to be particularly aggressive and discussion showed the staff member to be unaware of how she would be expected to diffuse or manage this situation. She said that she would ‘keep her distance’. This approach does not meet the service users needs and is likely to exacerbate the behaviours particularly as the staff member was aware that one of the triggers for behaviour is ‘if someone doesn’t speak to him’. A staff member had an intuitive basic understanding of her role in the event of her becoming aware of abuse but would benefit from the provision of Adult Protection training. No disciplinary action has been taken against staff but the Manager acknowledged that staff performance is not being managed. No physical restraints are employed at the home although two service users freedoms are subject to some voluntary restriction currently due to multidisciplinary risk assessment. Systems to manage service users finances have significantly improved. This is the single greatest improvement since the last inspection. Financial records are now available and accessible. Service users have a ‘Society’ bank account where all transactions are accountable. Monies held by the home when withdrawals are made from the bank on service users behalf are also well documented with receipts available. The Inspector checked cash in hand as correct against recorded balances. It was noted that interest on savings is not available to service users in the type of account set up although the Inspector was informed that superfluous money is limited by the constraints of appointeeship. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 The premises are adequate but require a general upgrade including redecoration, new furniture and carpeting. More action is required to improve infection control practice. EVIDENCE: The lounge requires modernisation to provide a brighter, fresher living environment for service users. Externally windows have deteriorated and will require attention. Service maintenance records are up to date assuring the safety of the premises and outstanding requirements to ensure the safety of the water supply have now been fully complied with. Some new furniture has been ordered, new dining chairs (with tables to follow) were delivered on the day of inspection and the proprietor has submitted an improvement plan to CSCI for the replacement of priority furniture and redecoration which it is intended to do within 12 months. At the last inspection the proprietor and Manager had identified the need to replace a service users bed to offer her better protection. This was included as a requirement but has not been complied with. Professional support has been requested to help ascertain the correct bed for the service user but there have been delays and procrastinations. A service user spoken to said he would like new wallpaper and curtains, stating that although it was clean, he’d ‘like everything new’. On the day of inspection the proprietor interviewed and appointed a handy man Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 21 subject to checks and references. This will further help to maintain and improve the environment. Plans are in place to renew and extend the shower. The manager has not obtained the advice of an Infection Control nurse but has devised and implemented an infection control policy to guide practice. The Inspector found the laundry to be clean with no malodour. Floors and walls are washable, with walls having recently been painted, and personal protective equipment and soap were available with the exception of aprons. There is some concern that personal protective equipment is not always worn when carrying out personal care and laundry tasks and this should be reviewed. Consideration has not been given to how to minimise cross infection risks when transporting soiled linen throughout the home and past eating areas to access the laundry. Hand wash signs are not available in the laundry, domestic washing machines do not reach 65 degrees and appropriate sluice facilities are not available to minimise infection risk. The external clinical waste bin was overfull and therefore the lid could not be closed or secured contrary to good infection control practice. The Inspector was told that the contractor who collects such waste was unusually overdue and that this would be monitored. An Environmental Health Officer had assessed kitchen in January 2006 and subsequently issued some requirements for improvement. A cursory inspection showed cold and hot storage being maintained at appropriate temperatures safeguarding service users heath and well-being. Broken and splintered wood stockpiled at the rear of the garden poses some unnecessary risk to service users. Inspection showed an unsupervised service user to be handling this. However it was pleasing to see all external storage areas to be locked and this is an improvement upon the outcome of an earlier inspection. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Standards in relation to staffing are generally poor. Staff do not yet have the required competencies and qualities required to meet service user needs. Their competency is not being supported as access to written guidance, training, attendance at staff meetings, supervision and management of performance is poor. EVIDENCE: The number of care hours provided has increased since the last inspection from 301 per week to 346. This is a marked improvement but falls short of the proprietor’s intention to provide 365 care hours. The shortfall was attributed to maternity leave but there must be sufficient contingency arrangements to cover planned and unplanned absences. The manager is still providing 14 care hours per week out of his management hours. This is compromising the amount of time he is available to manage and improve the standards in the home and this is being reflected in the poor outcomes. The Manager needs time to make the necessary improvements. One extra staff member is now being provided on most peak time shifts. However staffing ratios assessed as required are not always being met. Weekend ratios are not as good as weekday ratios compromising weekend activity. Evening shifts still end at 9pm, which restricts service users taking part in age appropriate evening community activities. In addition assessment of the rota showed staffing ratios not to be met on Tuesday mornings because it has been custom Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 23 and practice to allow one staff member to finish her night shift early, leaving the shift short staffed from 8am – 10am. The shift must be covered. The Manager must ensure that the service is not run purely for the convenience of staff. It must be managed in a way that meets service users needs. A staff member expressed concerns about how the home is being managed and in spite of an excellent initial written appraisal has since become demotivated and unhappy. There was no evidence from records of sufficient training or from discussion and care record sufficient knowledge and therefore there is doubt about staff having sufficient skills and knowledge to meet service users needs in spite of NVQ targets having been obtained by over 50 of staff. Discussion with a staff member showed she had not seen care plans or risk assessments and did not understand service user needs including how to meet these needs. Job descriptions are unclear, there is no evidence of Codes of Practice. The Manager is reluctant to delegate key tasks to staff. Staff are not being well supported to understand their role and responsibility. Service users are better protected by an improvement in recruitment practices. Significantly staff are not starting in employment without Criminal Record and POVA checks and references. Omissions remain however which must be addressed. Written references could not be authenticated, employment history had not been completed at the time of application and there was no identification or photograph available on file. In addition there was no evidence of training stated by an applicant and the Manager said that this now cannot be provided by the staff member. Staff contracts are not on file and job descriptions need review. Because staff are multifunctional the manager had issued several different job descriptions which is not satisfactory and there was no evidence that the staff member had been aware of their issue. There is also no evidence that applicants are interviewed and no evidence of service user participation in staff selection interviews. There is also no evidence that the General Social Care Councils Code of Conduct has been issued to the new staff members. In house induction has been provided but induction to the required national standard has not been provided (training premises have burned down but contingency arrangements have not been explored or obtained). Supervision has not been provided to a new staff member within the first six weeks of employment. Supervision has not been provided in 12 months of a second staff member’s employment. This is not satisfactory. Supervision has been provided three times for many other staff. However if supervision is to be provided at regular meaningful intervals the home is not on target to have provided a minimum of six supervisions to all staff within 12 months. The staff member case tracked had not attended a staff meeting. This does not help the home to develop and move forward. The Manager should ensure that times of staff meetings are varied to encourage full participation. Discussion shows the Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 24 Manager to have some concerns about the performance of some staff but systems are not in place to promote and support improvement. The Inspector case tracked training available to a staff member in the last 12 months. To her credit in this time it was said she had started and successfully completed NVQ level 2 although certification was not available. There was no evidence of any other training having been provided. The manager said that a staff member had undertaken half a day Food Hygiene training but no certificate was available. The manager said that she had commenced infection control distance learning training, although there was no evidence to verify this. The staff member has not done fire training (instruction at induction), manual handling training, adult abuse / protection training, challenging behaviour / physical intervention training, health and safety training, equal opportunity training. No staff have undertaken disability awareness, epilepsy awareness, diabetes awareness, risk assessment awareness or training in nutrition. A service user living at the home is epileptic and one service user has very recently been diagnosed as diabetic and training for staff will support the meeting of these service user needs. Some staff have nearly finished a course in dementia. However no service users at Ormidale House have diagnosed dementia. Four new staff need training in adult abuse and protection. Moving and Handling training and Health and Safety training had been booked by the home but subsequently cancelled by the training provider due to a fire at their premises. Contingency arrangements must be explored. It is positive however that all staff with the exception of one have received first aid training. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Management performance is poor. There are weaknesses in the management which does not assure that service users are benefiting from a well run home, that is open and positive and run in the interests of service users. Service users can be assured that with some minor omissions in general the premises are as safe as reasonably practicable. EVIDENCE: The Manager is still working towards the required qualification. He said he has submitted his NVQ 4 for assessment with a view to continuing with his Registered Managers Award but is concerned that a fire at the local training centre will have destroyed his work. This has not however been confirmed and he has not had contact with the training centres representatives. In addition the Manager has completed basic food hygiene training in June 2006 and is working towards finishing a course in dementia course. He said that staff are due to finish their course in dementia soon. None of the servce users at Ormidale House have diagnosed dementia. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 26 Discussion with the Manager during this inspection confirmed a growing awareness that the Manager needs to develop a greater understanding of his role and needs to be facilitated by the proprietor through the provision of more care staff to release him to spend all of his time managing to make the necessary improvements. There are a disproportionate number of requirements for improvement and the number is not reducing. This is not the sign of a progressive home. The Manager stated that he was disappointed finding the outcome of the inspection ‘less constructive’ or positive than he had hoped. He felt that more improvements had been made than were evidenced. A staff member said that ‘the Manager is ok but he doesnt always tell people when they are doing things wrong. Some staff think they are above him and show him no respect.’ So he doesnt direct them.’ The staff members fear of repurcussion does not reassure that the manager has strategies for enabling staff to voice concerns with a reward for innovation, creativity, development and change. Failure to inform CSCI of adult protection concerns up to 18 months ago and more recently does not assure that the processes of managing the home are open and transparent. The Manager has demonstrated an awareness of his need to develop his approach in this respect. This was evident in the inspection from discussion arising from his devising the rota around staff preference and to his attending medical appointments with service users on his day off. Staff have been permitted not to attend staff meeting because the time of meetings is not convenient and does not coincide with their contracted hours. Outcomes show a persistent acceptance of the status quo rather than working creatively to overcome obstacles and achieve change. Six staff meetings are evidenced for 2005 but only one (in January) in 2006 to date. Absent staff are not reading or signing staff meeting minutes. Lack of appropriate direction and support can lead to an unhappy team. A staff member said that there is conflict amongst the staff group and that there isn’t a happy atmosphere. Additionally s/he was fearful of the repercussions of having spoken to the Inspector. The Manager is now having regular supervision which is well documented. This is being provided by a Consultant funded by the proprietor. This represents some improvement in the amount of support available to the Manager but there are some limitations when the supervisor is not the line manager. The proprietor and Manager meet regularly and the benefits of recording these meetings formally was discussed. No progress has been made to devise and implement a quality assurance tool although the consultant is carrying out ‘arms length’ regulation 26 visits to the home. This is an improvement but a tool has not been purchased as muted at the previous inspection. Systems are not in place to support the home to rigourously assess its own performance across all areas and to take action where shortfalls are identified. Service users views do not systematically underpin the homes development as systems are not in place to sufficiently seek their views formally and robustly. The views of third parties are also not sought. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 27 The Fire Officer last inspected the home in June 2005. Fire drills are held regularly and fire equipment serviced and checked in house reguarlly. The training matrix indicates that ten out of ten staff have had fire training but certificates are only available for 6 dated July 2005. Fire training for 4 staff cannot therefore be evidenced and this was partly confirmed by case tracking and talking to a staff member who said she had not received fire training. A risk assessment for a service user who smokes is not in place. Risk of burns and scolds is appropriaelty managed. Water outlet temperatures are controlled by valves and water temperatures are checked and recorded regularly. Records showed water temperatures to be within safe ranges. Radiators are all guarded to reduce the risk of burns from surface heat. There are no open or exposed fires. Certification is now in place to show that the water supply is currently safe. This marks an improvement. Hazardous chemicals are stored safely although it was of concern to find prescribed Sudocream in an unlocked bathroom cabinet particularly as it was prescribed for an unknown person. This was immediately removed. Accidents are recorded and are infrequent with there being only 2 accidents recorded since the beginning of 2005 and these were both in relation to a seizure suffered by the same service user. Gas and electrical safety is evidenced appropriately. There is a well stocked and readily available first aid box and all staff with the exception of one have first aid training. All wardrobes are chained or bracketed to minimise the risk of them toppling onto service users. Previous requirements to carry out specific risk assessments have not been carried out and the home would benefit from a written formalised and agreed contingency plan in the event of an emergency. Environmental risk assessments that are in place are generalised e.g. use of the stairs for service users and do not address the specific risks and variables for individual service users. Inspection of the rear garden found one service user to be handling stockpiled rubbish including wood remnants and splintered wood stacked at the far end of the garden adjacent to the remnants of a bonfire. Arrangements must be made without delay to safely dispose of this and to make the area safe in the meantime as discussed. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 1 32 1 33 2 34 2 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 1 14 X 15 1 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 2 X 1 1 1 X X 2 X Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 29 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 YA2 Regulation 14(2) Timescale for action The Manager must review whether 30/06/06 the home is an appropriate placement for the 2 service users subject to adult protection investigation and whether these service users needs can be met. New Requirement at May 2006 The Home needs to:• Consider how person centred planning can be incorporated into the care planning system in order to demonstrate involvement from service users and their families/advocates. Consideration must also be given regarding producing care plans in a format suitable for service users at Ormidale House. 31/08/06 Requirement 2 YA6 15 • 3 YA6 17(1)(a) Sch 3(2) Requirement first made and not met since October 2003. Review meetings must be evidenced i.e. through the provision of minutes. This requirement was first made and not met since November 31/10/06 Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 30 2004. Review of care must take place every six months with the service user, family and other appropriate third parties Multi disciplinary review meetings must be held for each service user within the next six months. New Requirement at December 2005 Care plans must include guidance 30/06/06 as to how all service users needs in respect of health and welfare are to be met. Guidance must be specific and must outland the frequencies of care to be provided. New Requirement at December 2005 All care staff must be familiar with all service user care plans (to ensure staff are aware of need and how they are to meet service user needs) and must sign to indicate this. New Requirement at May 2006 The Home should:• Ensure that care plans contain specific details as to what type of support and tuition are needed to assist individual service uers with managing their finances as required by the NMS 7.5. 4 YA6 15 5 YA6 15 30/06/06 6 YA7 12(2) 30/06/06 7 YA7 12 Requirement first made and not met since October 2003 Care plans must include guidance on how service users make decisions, support required to do so and where decisions are made by others and why New Requirement at May 2006 All care staff must read risk DS0000065596.V296867.R01.S.doc 30/06/06 8 YA9 13(4) 30/06/06 Page 31 Ormidale House Version 5.2 assessments in respect of service users and the premises and must sign to indicate this. Risk assessments must improve. The advice of the Environmental Health Department must be sought in relation to this. 9 YA11 New Requirement at May 2006. 14(i)(d) 16(2)(b) The following needs/requests made by TY must be met: • • • To attend church. To do sewing/cross stitch at home. To maintain independent living skills such as vacuuming. 30/06/06 10 YA13 12, 15 These requirements were first made November 2004 and were not assessed at July or December 2005 Residents must be supported to execute their right to vote. (Residents not offered opportunity to vote at general election 5.5.05 or local election May 06) Requirement first made and not met since September 2004 30/06/06 11 YA14 12(1)(a)(2)(3) 15 Independent living skills must be included in plans of care and implemented. Plans of care must reflect service users individual interests and outcomes must be monitored. More regular community access must be facilitated and evidenced in line with individual service users specific interests. The proprietor must meet residents’ 7-day holiday costs (not assessed May 2006). This requirement was first made 30/06/06 Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 32 and not met since November 2004 12 YA13 12 An individual activity programme must be established, implemented and monitored for each service user based upon assessed interests, preferences and aspirations of each service user. Activity outcomes must be evidenced to facilitate monitoring of the plans effectiveness. The Manager must ensure that staff time with and support for service suers outside the home is flexibly provided, including evenings and weekends and that this is a recognised part of staff duties (ie review current practice of evening shift ending at 9pm) New Requirement at May 2006. 13 YA15 12 Arrangements for contact with family and friends for all service users must be reassessed and outcomes included in service users individual plans of care. Any agreements must be complied with and contact accessibly evidenced New Requirement at May 2006. 14 YA17 Sch 3(3)(m) Sch 3 (13) Nutritional risk assessments must be regularly reviewed and action taken without delay when risk is highlighted e.g. seek medical advice, put nutritional care plan in place ensuring that all staff adhere to it. New Requirement at July 2005 and not fully met at December 2005 – See immediate requirement issued at this Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 33 30/06/06 31/08/06 12/05/06 inspection May 2006. 14 YA14 17 S 3(3)(m) S 4(13) 13 The registered Manager must 12/05/06 carry out nutritional risk assessments for ‘F’ (and all other service users), assessing the level of risk, taking appropriate documented action where required to fully safeguard and promote ‘F’ and all service users nutritional health and welfare. (Nutritional risk assessments must be kept under regular review) Medical advice must be sought in respect of ‘F’. Immediate Requirement at May 2006. 15 YA19 12(1) 13(1)(b) Annual sight, hearing tests must be provided for all residents. The manager must ensure that advice is sought from medical authorities about sexual health screening for residents and included in care plans. This requirement was first made November 2004 and not met at December 2005. 16 YA19 13 All service users must be with sufficient regularity offered all health screening including dental checks. New Requirement at December 2005. 17 YA19 17(1)(a) Care record systems must be reviewed to ensure improvement. The recording of Health appointments must improve. New Requirement at May 2006. 18 YA20 13(2) The medication policy must include arrangements for the transportation of medication and must state that medication must 31/08/06 30/06/06 31/07/06 30/06/06 Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 34 not be double dispensed. This requirement was first made and not met since November 2004 19 YA20 13(2) The manager must ensure that the 30/06/06 home receives quarterly pharmacy support visits to the home and that records are abvailable to evidence outcomes. New Requirement at May 2006 20 YA21 12 Service users wishes in the event of death must be assessed and recorded. New Requirement at December 2005. Not Assessed at May 2006 21 YA22 22 The complaints policy must be in an accessible format for service users and must be readily available to them. New Requirement at July 2005. Not assessed at December 2005. 22 YA22 22 The manager must ensure that steps are taken to ensure that all service suers know how to make a complaint. Steps taken must be evidenced New Requirement at May 2006 23 YA23 13(6) A policy to guide the management of service user finances must be written and be made familiar to staff. New Requirement at July 2005. Not assessed at December 2005. 24 YA23 13(6) 37 All adult protection allegations (and all other incodents affecting the helath and welfare of service users) must be made known to CSCI without delay DS0000065596.V296867.R01.S.doc 30/09/06 31/08/06 30/06/06 31/08/06 30/06/06 Ormidale House Version 5.2 Page 35 The Manager must forward a report to csci outlining chronologically the sequence of events in realtion to adult protection incidents over the past 18 months that have not been reported to CSCI. The report must include allegations made and processes followed by the home, outcomes, any statements taken etc. and all documentation arising from these incidents. A behaviour plan must be devised for all service users who require support to manage behaviour including FL. Adult protection training must be provided to the 4 staff who have not undertaken this training – to be booked by date given New Requirements at May 2006. 25 YA24 23(2)(n) 12, 13 13 (4) A person competent to do so must assess the effectiveness of the extraction system in the smoking room. Any action for improvement identified must be taken. New Requirement at May 2006 26 YA24 23 13(4) 12, 13 The broken and splintered wood at 10/05/06 the back of the rear garden must be removed and steps must be taken in the meantime to reduce arising risk to service users. New Requirement at May 2006 27 YA30 13(3) 23(4)(a) 13(4) The manager must seek the advice of the Infection Control Nurse and / or the Environmental Health Department. Requirements first made and not met since September 2004. 28 YA30 13(3) The manager must review the use of personal protective equipment to ensure that all staff are fully and correctly using it. DS0000065596.V296867.R01.S.doc 30/06/06 31/08/06 31/05/06 Ormidale House Version 5.2 Page 36 New Requirement at May 2006. 29 YA33 18 Care staffing hours provided per week must be reviewed: Consideration must be given to: • Ratios of staff required on each shift to meet need, safety and promote activities and choice. Needs/ safety at peak times. Care hours (14) currently provided by the manager, which detract from his management role. 31/05/06 • • Assessed outcomes and action taken must be confirmed in writing to the Commission for Social care Inspection by the date set. New Requirement at December 2005. 30 YA33 18 The proprietor and Manager must ensure that a minimum of 365 care hours are provided as assessed as required. The manager must confirm in writing to CSCI minimum care staff ratios to be on duty on each shift Monday to Sunday and this must be maintained at all times. The Provider must ensure that there are sufficient care hours to release the Manager to be fully supernumerary in order to fully apply himself to managing the home and improving its performance. New Requirement at May 2006 31 YA34 13(4) 19 The volunteer policy must be expanded to state that full checks and references, support and training will be undertaken in line DS0000065596.V296867.R01.S.doc 31/05/06 31/08/06 Ormidale House Version 5.2 Page 37 with the recruitment policy for staff. Requirement first made and not met since September 2004. Not assessed at December 2005. 32 YA34 19 The home must ensure that: • All gaps in employment history are explored 31/05/06 Requirement first made and not met since October 2003. Not assessed at December 2005 33 YA34 19 All recruitment checks and 31/05/06 documentation as per Schedule 2 must be obtained and must held on file prior to the appointment of new staff. New requirement at inspection July 2005. The Manager must review all recruitment documentation and ensure that all required documentation is present for existing and current staff. New Requirement at May 2006. 34 YA35 23(4)(d) The manager must develop a training needs assessment for the team as a whole and each individual staff member. Each staff member must receive at least 5 paid days (evidenced) training per year. All staff must receive training in recognising and reporting abuse. All staff must receive training in equal opportunities including disability and anti racism training. An action plan outlining dates for the provision of appropriate training for all staff must be Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 38 31/08/06 provided to the Commission for Social Care Inspection. This requirement was first made and not met / evidenced since November 2004 35 YA35 18 A programme of training must be booked for each staff member to ensure each staff member receives all mandatory training and knowledge specific training to meet service users specific needs e.g. epilepsy and diabetes awareness training. All training must be booked by the date given. The manager must undertake risk assessment training. Advice must be sought from the Environmental Health Department about the level of training required. All staff must be provided with risk assessment awareness training. Ya 35 – All staff and the Manager must receive nutrition training Ya35 – All staff must be provided with managing challenging behaviour training Ya35 – All staff must receive annual fire training. The Fire Service must be consulted about the sufficiency of current training being used. Ya35 – Staff for whom there is no evidence of fire training within the last 12 months must be provided with Fire training without delay and this must be confirmed in writing to CSCI. New Requirements at May 2006. 30/06/06 36 YA35 18 All documentation required by regulation including staff training DS0000065596.V296867.R01.S.doc 31/05/06 Ormidale House Version 5.2 Page 39 certificates must be retained on the premises, must be up to date and must be available for inspection at all times. New Requirement at inspection, July 2005. Not assessed at December 2005 37 YA35 18 New staff must be provided with 30/06/06 induction training to the required standard and within the required time scale. New Requirement at inspection, July 2005 At December 2005 trainer identified for next new staff member. At May 2006 training premises burned down The homes to further enhance the 31/08/06 supervision sessions to cover care practices and the individual’s strength’s and weaknesses. Requirement first made and not met since October 2003. 39 YA36 18 All staff must receive a staff appraisal annually that identifies strengths, training needs and areas for improvement where appropriate All staff must receive a minimum of 6 regular recorded supervisions a year that as a minimum covers all areas as per National Minimum Standard 36.4. 40 YA39 New Requirement May 2006. Develop an effective quality assurance system. Requirement first made and not met since Prior to October 2003 Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 40 38 YA36 18 31/10/06 24 30/09/06 41 YA41 17 Ensure that records required by regulation and those identified within this report are available for inspection. Requirement first made and not met since September 2004. 30/06/06 42 YA42 23, 13 The home to ensure that risk assessments are carried out for all safe working practice topics and that significant findings of risk assessments are recorded. Requirements first made and not met since March 2004. 30/06/06 43 YA42 13(4) 23 A written risk assessment must be carried out in respect of the bedroom window, which is internally climbed on to by the occupying service user. Advice must be sought from the Environmental Health Department. New Requirements made at inspection, July 2005 and not met at December 2005. Risk assessments must be carried out in respect of all service users who smoke New Requirement at May 2006. 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA8 YA31 Good Practice Recommendations The home to consider how the service user’s can be involved in the selection of new staff to the home. The manager should review staff job descriptions to ensure that staff roles are clearly defined. Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 41 New Recomendation at May 2006. 3 YA38 The management should consider ways of developing strategies for enabling staff to voice concerns and reward for inovation, creativity, development and change. The manager should review staff meeting times to encourage all staff to attend. New Recommendation at May 2006 4 YA40 The manager to consider signing and dating all policies and procedures Ormidale House DS0000065596.V296867.R01.S.doc Version 5.2 Page 42 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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