Inspection on 14/08/07 for Radnor House

This inspection was carried out on 14th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Radnor House 08/11/06

Radnor House 08/02/06

Radnor House 27/07/05

Radnor House 19/01/05

Radnor House 09/08/04

Radnor House 05/02/04

Radnor House 01/10/03

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

CARE HOME ADULTS 18-65 Radnor House 29/31 Radnor Road Handsworth Birmingham West Midlands B20 3SP Lead Inspector Kulwant Ghuman Key Unannounced Inspection 14th August 2007 11:30 Radnor House DS0000016871.V349272.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 Radnor House DS0000016871.V349272.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. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Radnor House Address 29/31 Radnor Road Handsworth Birmingham West Midlands B20 3SP 0121 523 6935 0121 240 9051 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) Mr Leslie Latchman Mr Alfonso Latchman, Mrs Kamla Devi Latchman, Mrs Silvena Latchman Mr Leslie Latchman Care Home 29 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (29) of places Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can care for service users over 40 years of age for reasons of mental disorder including those who are over 65 years of age. The home must ensure that the changing care needs of the older service users can be met and that these care needs remain under regular review. The home can accommodate two named service users for reasons of mental disorder who are over the age of 65 years. 8th November 2006 Date of last inspection Brief Description of the Service: Radnor House is a large detached house accommodating 29 people in the Handsworth area of Birmingham. The home provides ongoing support for people with enduring mental health needs and partly focuses on their rehabilitation and to be more independent. The home is close to shops, a public park, local health centre, community centres and various places of worship. There is a short walking distance to public transport links for Birmingham and West Bromwich. Limited off road parking is available. Facilities available at Radnor House include 27 single rooms and one double room. Communal facilities consist of three lounges and two dining rooms. There are three toilets on the ground floor one includes a bath. On the first floor there are two bathrooms and a shower room with toilet. The second floor has two shower rooms both with toilets. The bathroom on the first floor has provision for assisted bathing. All bedrooms have wash hand basins. Facilities are available to prepare hot drinks in the lounges. A passenger lift connects all floors of the home. The home has a large rear garden. The current fees at the home are between £339 and £456 per week. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced, key inspection over one and half days during August 2007. The inspector was able to talk with nine of the twenty-eight people who lived in the home, four staff and the manager. The people living in the home all had enduring mental health illnesses and were not always able to communicate their views and opinions. The care files of two people who had moved into the home recently and of two staff who had been employed in the home recently were looked at. A tour of the building was carried out and nine bedrooms were seen as well as the communal areas of the home. Health and safety records were sampled to check on the servicing of equipment and tests being carried out in the home. Prior to the inspection the manager had completed and returned the Annual Quality Assurance Assessment to the Commission that provided the inspector with some information about the home. Four people living in the home and one relative completed surveys that were returned to the inspector and they all indicated that they were happy with the service being provided by the home. No complaints or adult protection issues had arisen regarding the home. What the service does well: The home encourages the people who live in the home to live individualised lifestyles that reflects their culture, religion and individual likes and dislikes. The people living in the home are encouraged to be involved in the local community by attending work or college, going to the local shops, attending medical appointments in the community and maintaining contact with friends and relatives where possible. The manager and staff team encourage the people living in the home to be considerate towards each others needs and respect each others rights for example, not to barge into other peoples bedrooms or to lock their bedroom doors to stop others going in. The people who live in the home are supported to care for their belongings and manage their finances by helping them to budget. The majority of people living in the home were happy with the food being provided. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The environment needed to be improved to make it brighter and more homely. There was some furniture in some of the bedrooms that needed to be replaced, the standard of cleanliness in at least one bedroom needed to be improved and the external guttering needed to be seen to. Compliance checks for people who managed their own medicines needed to be recorded. Where the dietary intake of people living in the home needed to be monitored the records should show the amounts eaten. Improvements could be made to the menu to ensure that there was less repetition of meals and the records needed to show what was being cooked for example, what was the vegetable curry each day. The hot water temperature of one shower needed to be restricted to 43degrees centigrade. The training matrix for staff needed to include information that indicated whether appropriate refresher training had been provided to the staff. New staff needed to complete an induction-training programme in line with skills for care within four months of starting employment. A full work history needed to be obtained for staff and evidence kept that any gaps had been queried and accounted for. The home needed a quality assurance system to ensure that a development plan was put in place that took into account the views of the people living in the home. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Radnor House DS0000016871.V349272.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 Radnor House DS0000016871.V349272.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were enabled to visit the home before they moved in to ensure that they wanted to move in and so that their needs could be assessed by the staff. EVIDENCE: The files of two people who had recently moved into the home were examined. They showed that the individuals had been able to visit the home before deciding to move in even though the home they had been living in had had to close at very short notice. The home had assessed their needs at this visit and decided that their needs could be met by the home. Due to the emergency nature of the admission it had not been possible for the home to get the social worker assessments before the individuals were admitted. The manager needed to ensure that the social workers provided this information as soon as possible after the admission. Three of the people living in the home provided information to the inspector indicating that they had been helped to move into the home. Comments made by other people living in the home indicated that they were quite happy at the home. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home were supported to make personal choices and lead lifestyles of their choosing. EVIDENCE: The two files sampled included assessments that detailed many aspects of the peoples’ lives including mental state, daily living, medication personal hygiene, social needs and general health. The assessment forms were reviewed on a six monthly basis. The majority of the people living in the home were able to undertake personal care tasks but needed some prompting and supervision. There were details on their files about their likes and dislikes and risk assessments which indicated what staff needed to do if the individual refused to respond to requests from staff. The assessment forms did not have a lot of detail in how some of the needs of the people living in the home were to be met, however, there were monthly evaluation sheets that included a lot more detail for some of the areas of need. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 11 The inspector was informed that the monthly evaluation sheets in conjunction with the assessment sheets formed the individual care plans. All the relevant information was available for the staff to access in these documents but there were a lot of papers that the staff would have to read through to get a picture of the individual’s needs. It would be better if the home gathered the information from the assessments and formulated a care plan document that informed the staff on how the needs of the individuals were to be met. It would also be good practice for the care plans to include some aims and objectives that the individuals could work towards achieving with the assistance of the staff. This would ensure that they were encouraged to develop their independence and daily living skills. Two members of staff spoken with during the inspection were able to identify how individuals were assisted to make choices. For example, one person with dementia was allowed to dress in the mornings and then assisted to change into more appropriate clothing if they had not got it quite right. Another person living in the home bought his tobacco from the local shop and the staff bought things like clothes. The level of interaction between the people living in the home and the manager regarding their finances was very pleasing to observe. It was obvious that this was a regular occurrence. They were advised as to what their current financial situation was, the amount of money that was available to them and how any shortfalls could be rectified from a variety of sources. They were given small amounts of money as they needed it and signed the records to indicate they had received it. There were regular meetings in the home with the people who lived there and discussions were had about the menus and activities and recently about the impact of the smoking ban in public places. The staff were assisting and encouraging them to smoke only in designated areas of the home. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at the home were able to meet the varied individual lifestyle needs of the people living there by promoting choice and access to the local community. EVIDENCE: Some of the people living in the home had a key to the front door but others did not because they let one of the people with dementia go out of the home alone which put him at risk. Another reason for some people not having the key was that unwelcome visitors were coming into the home. Whilst it was admirable that the manager tried to care for people in the home for as long as possible he needed to monitor the situation closely so that the other people living in the home were not being restricted for the sake of one person. Also there may come a time when the dementia care needs of the person discussed during the inspection cannot be met adequately in this home. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 13 During the inspection people living in the home were observed to go to work at the BITA travelling by public transport. One person informed the inspector that she had reduced her attendance due to pain in her legs. The person also told the inspector that she was able to make curries in the kitchen for herself. Several people living in the home were accessing local community resources including shops, pubs and cafes. Some people had been out to the Safari Park and holidays were arranged if they wanted to go. One person living in the home told the inspector how her key worker took her out quite often. The local mental health teams provided support for some of the people living in the home. There were regular visits from and to families by some of the people living in the home and they were able to visit whenever they wanted. One survey returned by a relative stated that they had always been made welcome at the home and the needs of their relative were being met. Three of the people living in the home spoken with said that they were happy with the food and that choices were available but one said that they did not like the food and that there was the same thing on the menu day after day. There was a two weekly cyclical menu in the home however there were several meals that were repeated during that fortnight. The home needed to look at varying the meals so that there was less repetition over the fortnight. There were no records of daily food intake for the majority of the people living in the home. The menus were available for inspection and the people living in the home said the meals were written up on the board in the dining room each day. The menus did evidence that cultural dietary needs were being catered for and on most days vegetable curry was available, although it did not state whether it was the same vegetable curry or if there was a variety available. There were also some Caribbean foods available on the menu. There were food records for people whose dietary intake needed to be monitored. These could be further improved by indicating the amounts of food eaten as well. The manager stated that the nutrition and variety of the meals provided at the home could be determined from the menus and that the people living in the home could verbally state what they had eaten. However, although this may be possible for the past week or so this may not be possible over a longer period of time. It was agreed that food records would be kept for individuals with dementia who could not say what they had eaten. It was recommended that food records should be kept for all the people living in the Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 14 home. There was plenty of food available in the home. The environmental health officer had been to the home on 26.6.07 and the requirements made were in hand. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was able to support the people living there to maintain their personal and healthcare needs in an appropriate manner. EVIDENCE: The care files sampled during the inspection indicated that the level of support required by the people living in the home to maintain their personal care was varied. Some needed prompting and supervision whilst others needed more support on a one to one basis. From discussions with the staff it was evident that they were aware of the level of support individuals needed and how they could promote their choices and independence on a day-to-day basis. The people living in the home were seen to have their own styles of dress and they were supported to maintain this. There was evidence that the physical and emotional health of the people living in the home was monitored on a day-to-day basis and there were good relations with the support services. Individuals were helped by the staff to Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 16 make appointments and were often escorted to the appointment. During the inspection some visiting medical professionals were seen in the home. The home managed all the medicines for the people in the home in terms of ordering, storage and disposal. Individuals living in the home could administer their own medicines if they were able to manage this. One of the individual’s medicines that were audited during the inspection was administering his own medicines. There was a risk assessment in place but this had been undertaken in 2005. The member of staff assisting the inspector stated that she did discuss the medication with him and checked the blister packs but this was not recorded anywhere. It was important to record the compliance checks to identify if there was a gradual decline in the ability to self medicate. The medication was well managed and this ensured that the people living in the home were receiving their medication as needed and as prescribed. There were photos of the individuals for whom the medication charts related to and known allergies were recorded. The inspector was informed that all staff who administered medicines had had the appropriate training. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does demonstrate it has the resources and processes to effectively manage complaints and protect vulnerable people living in the home. EVIDENCE: No complaints had been logged at the home and none received by CSCI. One of the people living in the home had told the inspector that things had gone missing from her room. During discussions with the manager it was determined that these items had been found in her bedroom later on. No record had been made of these allegations or that the items had subsequently been found. It would be good practice to record any allegations made and the actions taken in response to show that the individuals were being listened. In addition, where this was happening on a regular basis it would show that there was previous history of this happening and that things were normally found at a later stage. During the inspection the same person informed the manager that during the previous night someone had tried to get into the home and she had become frightened. She had activated the emergency call system but the staff had not responded in a timely manner. The manager was unaware of this and stated he would look into the matter. No issues of adult protection had been raised in the home and where there had been altercations between people living in the home the police had been called Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 18 when one of the parties had requested it evidencing that their rights were promoted. The home did look after the monies of most of the people living there. Although the system was not checked during this inspection it was obvious from the interactions between the people living in the home and the manager that everything was clear and open in respect of the records. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment met the needs of the people living in the home but some decoration of the home was needed. Some bedroom furniture needed to be replaced. EVIDENCE: The premises generally met the stated aims and objectives of the home but there were several areas of the home that did need to be brightened up and redecorated. There were suitable bathing facilities on all floors and a choice of bath or shower was available to the people living in the home. The temperature of the hot water being delivered by the shower on the second floor was not restricted to 43 degrees centigrade and this needed to be done to ensure that the people living in the home are not at risk of scalding. The flooring had been replaced in the toilet and bathroom areas. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 20 There was liquid soap and paper towels available in all communal areas of the home. The laundry was sited in a small outhouse and included a washing machine with a sluice cycle. There were hand-washing facilities available in the laundry. The bedrooms sampled during the inspection showed varying levels of individualisation according to the wishes and needs of the people occupying them. One of the bedroom doors did not close automatically onto its rebate and this was particularly important in a home where the people living there tended to smoke in their bedrooms. One of the bedrooms seen was in need of cleaning and the manager made arrangements for this to be addressed. One bedroom carpet and some beds were in need of replacement. were due to be done as part of the refurbishment programme. These There was a communal lounge on each of the floors. The furniture in these rooms had been replaced. There was a television available in all the lounges except on the second floor which was currently being used for storage of excess furniture and a snooker table. The manager said that this lounge was rarely utilised by the people living in the home. There were two dining areas for the people living in the home to use and the kitchen appeared to be clean and well equipped. The kitchen was not looked at closely as the Environmental Health Officer had been in the home recently and the inspector was told that the requirements made were in hand to be addressed. The garden was not seen during this inspection due to the heavy rainfall at the time of the inspection. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels appeared to meet the needs of the people currently living in the home. There is training available to equip staff to be able to carry out their roles. Some records needed to be improved. EVIDENCE: The people living in the home that were spoken to said that the staff were helpful and kind. There were good interactions seen between the staff and the people living in the home and there appeared to be a good understanding of their needs of by the staff. The inspector was informed that there were always three support staff on duty during the day in addition to the management team. There were two staff on duty during the night. The staffing rotas confirmed this and indicated that there was a cook available five days a week. The hours of the cook were not identified on the rota but the inspector was informed that she was on duty 10am til 1pm each day. Support staff prepare the breakfast and tea. At weekends allocated staff prepared the meals. The domestic hours and names of the individuals carrying Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 22 out these duties were not identified on the rota but during the inspection there was an individual undertaking these tasks. People living in the home commented on how hard the individual worked. Two staff files were sampled during the inspection and it was noted that in general the recruitment procedure safeguarded the people living in the home with the appropriate pre-employment checks being undertaken. The application form format did not however, enable a full employment history to be obtained and any gaps queried. The manager stated that he would ask for a CV (curriculum vitae) to be provided in future. The two files did not evidence that an interview had taken place as there was no record of the questions asked or the responses made. There were no terms and conditions of employment on the files so it could not be determined when the individuals had actually started work at the home. For one of the individuals there was a copy of a CRB form on the file from their previous employment. The manager stated that a POVA First check had been undertaken but that the evidence was on his computer that was not available in the home at the time of the inspection but that was due to be linked up. The inspector was shown an induction programme that appeared to be in line with the Skills for Care guidelines but there was no evidence available at the time of the inspection that the two individuals had undertaken a full induction. The training matrix provided did not indicate whether induction training had been undertaken. The matrix indicated that the staff had had or are currently undertaking all mandatory training but it could not be determined from this if refresher courses had been provided where needed as there were no dates of the training on it. Dates were said to be available on the individual files. More than 50 of the care staff have NVQ level 2 training and training was being provided by a variety of providers. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and safety in the home was well managed and there were good relations between the staff and people who lived in the home. EVIDENCE: The people living and working in the home seemed to have good relationships with each other. The people living in the home were receiving appropriate support and guidance to make decisions about their lives. The office doors were open to the people living in the home and it was observed that they often went to chat with the staff. The manager had a genuine understanding and respect for the people living in the home and was able to guide the staff team in a manner that engendered a respect for him. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 24 There were regular meetings for the people living in the home to discuss issues that were pertinent to the running of the home such as not letting someone who lived in the home out without the staff knowing and the need to restrict the areas where smoking could be undertaken. The manager told the inspector that there was no formal quality assurance system in place yet but that he had obtained a system that he would be implementing in the home. This issue was also raised at the previous inspection. Health and safety at the home were generally well managed with servicing of equipment and the fire system being regularly checked. The home had had a recent visit from the West Midlands Fire Service and the systems in place were found to be satisfactory. The hot water temperature from one of the showers needed to be restricted to 43 degrees. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 25 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 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13(2) Requirement Risk assessments for people managing their own medicines must be updated on a regular basis. Records of compliance checks with the people managing their own medicines must be kept. This will ensure that the abilities of people who are managing their own medicines is monitored to ensure they take their medicines as required and prescribed. The registered manager 30/09/07 must audit all furniture and fittings in the home and replace furniture and fittings that are no longer fit for purpose. The registered manager must provide a further programme of refurbishment to the Commission and complete the necessary work. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 27 Timescale for action 01/10/07 2. YA24 23(2)(b)(c) 3. YA32 18(1)(a) 4. YA34 17(2) Schedule 4(7). This will ensure that the people living in the home have access to a comfortable environment. All new staff must undertake induction training in line with the skills for care competencies to ensure they have the skills and knowledge to carry out their roles. The registered manager must ensure that a full employment history is obtained from potential employees and any gaps queried. The start date of employees must be recorded. 01/10/07 01/10/07 5. YA39 24 This will ensure that the only the appropriate people are employed in the home. The home must develop and 31/12/07 audit a system of Quality Assurance. Previous timescale of 31/8/05 and 11/01/07 not met, this requirement has been carried forward. This will ensure that the service is developed and meet the requirements of the varied stakeholders. Hot water temperatures must be restricted to 43 degrees in all bathing and showering facilities. The manager must ensure that all bedroom doors close fully on their rebates. This will ensure that everyone in the home are 6. YA42 13(4)(c) 14/09/07 Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 28 kept safe. 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 YA2 Good Practice Recommendations The home should ensure assessment information is obtained from the placing authority within 72 hours when someone is admitted to the home on an emergency basis. This will ensure that the home has all the relevant information on which to provide care to the individual. Information gained through the assessment process and monthly evaluations should be drawn together to form the care plan. This should give the staff information about how the aims and objectives for the individual’s health and social care needs will be met and by whom. This will ensure that the people living in the home will receive person centred care and develop their independence. The home should ensure that there is less repetition in the menus over the two weekly cycle and more detail should be included regarding what vegetables are to be served. This will ensure that the people living in the home have access to a varied diet. It is good practice to record what individuals have eaten on a daily basis to enable anyone carrying out an audit to determine that a varied and nutrition diet is being eaten. This is particularly important for individuals who cannot state what they want to eat and what they have eaten. Where dietary intake is being monitored for individuals the records could be further improved by including the amounts actually eaten. Any issues raised by the people living in the home, the actions taken in response and the outcomes should be recorded. This will evidence that the people living in the home are listened to and actions taken as a result. The training matrix should include dates for when training has been provided for staff. This will ensure that staff remain up to date in their skills and knowledge. The registered manager must ensure that the duty rota records the hours worked by all the staff in the home DS0000016871.V349272.R01.S.doc Version 5.2 Page 29 2. YA6 3. YA17 4. YA22 5. 6. YA32 YA33 Radnor House including ancillary staff and managers. Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Radnor House DS0000016871.V349272.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!