Inspection on 08/11/06 for Radnor House

This inspection was carried out on 8th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Radnor House 14/08/07

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 Sean Devine Unannounced Inspection 8 November 2006 08:35 th Radnor House DS0000016871.V308869.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.V308869.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.V308869.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.V308869.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can care for residents 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 residents can be met and that these care needs remain under regular review. 8th February 2006 Date of last inspection Brief Description of the Service: Radnor House is a large detached house accommodating 29 residents in the Handsworth area of Birmingham. The home provides ongoing support for residents with enduring mental health needs and partly focuses on the rehabilitation of residents 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. Whilst 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. Facilities are available to prepare hot drinks in two lounges. One lounge on the top floor has a snooker table. A passenger lift connects all floors of the home. 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. The home has a large rear garden. The manager advised on pre inspection information that the contractual fee for the home was up to £447.06. Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was undertaken over one day (9 hours) and was unannounced by one regulation inspector. The inspector was able to meet and talk with many of the residents, many of the staff and the manager. Residents have an enduring mental illness, which does at times impair the ability of some residents to effectively communicate and therefore their views and opinions of the service are at times unclear. Records about the social and health care of three residents were seen including care plans and medication, and staff informally discussed their practices. Health and safety records, tests and servicing were sampled and a tour of the communal areas of the home was completed. Records about complaints were seen, there have been no complaints to the home by concerned residents or their representatives and the Commission has not received any in the past twelve months. At the end of the inspection important issues were fed back to the manager, including the lack of care planning and implementation for one resident, however shortly following the inspection the manager provided good evidence that these were in place and that staff were adhering to them. Prior to the inspection an inspection questionnaire and resident survey letters (known as “have your say about…”) were sent to the home. The questionnaire and ten survey were returned to the Commission. What the service does well: The home actively encourages residents to be involved in assessing and planning the support they need. Comments from residents included “I can do what I want to do” and “the staff ask me what I have planned”. The home also ensures that care plans are about the individual person, this includes their choices of lifestyle (background, religion, culture, likes and dislikes) and their healthcare needs. The home has developed links with the local community and wider that enable many of the residents to attend centres for occupation, education as well as for health and social reasons. One resident informed the inspector “I have to dash as I need to get to work on time as I need to catch my bus” and another said “I enjoy BITA, it can be a busy day”. The home has a manager who is involved in local issues about health and social care, who ensures he keeps up to date with the changes in health and social care including representing the home at stakeholder meetings with the Commission. The residents and staff are positive about the managers’ Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 6 attributes; one resident said “I get on well with him, he’s great” and a member of staff said “you can talk to him, he’s often out of the office and talking with residents”. What has improved since the last inspection? What they could do better: Improvements are mainly required in two areas, with the priority being the environment. The manager advised that a programme to improve this area was in place yet little progress since the last inspection was seen. Residents do not have some fit for use furniture, such as armchairs; the flooring in some areas is inadequate and an audit to plan the refurbishment and redecoration is needed by the manager to identify all areas to improve upon. The second area is improving the amount of staff training; although staff do receive some training there are some gaps according to records, with the main concern being safe working practice training including fire safety. This will provide residents with staff who are skilled and who can support their health and safety and help with issues surrounding their mental illness. A requirement to develop a system of quality assurance has been made at previous inspections. The manager advised that he has been able to look at some other systems and will shortly start to implement a system at the home. He advised he is keen to include many residents who wish to be involved in the process and will share a report on quality with them and the Commission. Radnor House DS0000016871.V308869.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. Radnor House DS0000016871.V308869.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.V308869.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): Standards 2 and 5. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the ability to ensure residents are involved in making decisions on whether they would like to live at the home, they are provided with assessments and contracts that describe the home, facilities and services to meet the individual needs including their diverse cultural backgrounds. EVIDENCE: There have been no admissions to the home since before the last inspection. Three residents files were seen, including records about their assessments of need and abilities; these assessments are regularly reviewed by the manager and deputy manager. Some residents had been included in the assessments, however the managers said some other residents had declined. Many of the assessments described the physical, mental, social, lifestyles, relationships, occupation and pastimes of residents. Of the ten surveys returned to the Commission nine residents indicated they were asked if they wished to move into the home and nine also indicated they were provided with enough information. On the survey one resident commented, “I have been in one worse place and one better place” and “but it took a along time to settle”. Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 10 All three residents had a contract, which they had either signed or there was a declaration they had declined to sign, detailing the terms and conditions of their residency, including their accommodation, facilities and amount of fees to be paid. Radnor House DS0000016871.V308869.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): Standards 6,7 and 9. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home does demonstrate its ability to support residents through good care plans and risk assessments. Many of these reflect personal choices; lifestyles, routines and the health of residents. It is an inclusive process tailored to meet personal needs and aspirations of residents. EVIDENCE: Residents had plans that reflected their needs and abilities identified in the assessments. As with the assessments some residents had been involved and some had declined. The plans were varied reflective of very individual needs such as support with managing and handling benefits to support with shopping for clothes. The plans covered social and healthcare needs and were clear and concise and gave staff good instruction. The care plans are subject to regular review, this varies depending on the needs from one month to two months, however the manager advised that for some residents and if required it maybe more frequent. All residents on the survey indicated that they mostly make decisions of what they do each day, and that they can do what they want during the day and at night. Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 12 At the time of inspection the manager was advised that some identified needs were not fully covered by the care plans that were available, these included security in the home, socialising in the home and personal hygiene. Shortly after the inspection the Commission were provided with these revised assessments and care plans, it was evident the resident had been involved in the process. Risk assessments are available for residents, which clearly identify individual risks such as mental health relapse, medication and social needs and relationships. These very clearly describe the personal risk, the measures to reduce risk and the review states how effective it has been or otherwise. At the time of inspection the manager was advised that some identified risks were not fully covered by the available risk assessment, these included personal hygiene, reluctance to attend medical appointments and safety whilst smoking. Shortly after the inspection the Commission were provided with these revised risk assessments, again it was evident the resident had been involved in the process. Radnor House DS0000016871.V308869.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): Standards 12,13,14,15,16 and 17. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the capacity to meet the varied individual lifestyle needs of residents, by promoting choice, managing risks and having processes to support residents aspirations in a positive and inclusive manner. EVIDENCE: The residents’ assessments and care plans describe their individual lifestyles. The care plans can be fundamentally basic such as ensuring a resident has a morning call or more in depth such as to provide one to one support with developing cooking skills. On the day of inspection three residents who spoke with the inspector were going to work at the BITA in Digbeth and were travelling by public transport. They had an early breakfast and were seen speaking to staff about the day ahead. For some residents attending BITA is very important and they attend up to five times a week. Records made by staff reflect that residents do access local community facilities such as shops, libraries and have meals at restaurants. Further Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 14 records indicated that residents go out on day trips and some have had an annual holiday to Scarborough. One resident told the inspector he enjoys going to the local public house. For some residents the local mental health rehabilitation and recovery team provide additional support and take residents out, this includes social and leisure activities. Diary records often recorded visits by families and when residents go and visit family and friends. One resident told the inspector “my family see me, they just call in”. The rights of residents, their choices and preferences form the basis of all assessments and care plans this is clearly recorded. Any restrictions on residents are only implemented through the residents contract and through the risk assessment process; examples of these are respecting the privacy of other residents and complying with their prescribed medication. Several residents were seen to be dressed in a way that reflects their cultural and religious backgrounds and others were dressed in a way that reflects their individual choice and personality. The home operates a cyclical menu, it was evident from meetings with residents as a group and when reviewing care plans that their opinions are asked for and changes are made where possible. Residents are provided with meals that reflect their culture, the menu is diverse and provides options for residents, in the main it is healthy. The meals are of good portions and tasty. Three main meals are served each day, in addition there is “brunch” and “supper”. Residents spoke positively of the food saying “its really nice” and “I enjoy my meals”. The staff were also observed handling food safely. An environmental health officer visited the home on July 2006 and made some requirements, which the manager advised have all been completed, such as repainting some surfaces. For one resident it is written in the care plan that food intake needs to be monitored, records were available but had not always been thoroughly completed. Radnor House DS0000016871.V308869.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the ability to support the residents to access and receive individual personal and healthcare support in a timely and effective manner that promotes their well being. EVIDENCE: The residents’ care files indicated that the individual personal care needs of residents does vary; some residents require more support from staff than others, this is clearly recorded in the assessments of need and care plans where staff are given specific guidance about the level of support; for example style of dress, whether residents prefer a shower or a bath and whether this is preferred morning or at night. For some residents neglecting their own personal care is seen as an indicator of mental health relapse. For one resident a specific risk assessment about personal hygiene was seen, it did in part contain some good measures, however it did record that for periods the resident had refused to bath, and did not instruct staff what to do in this situation; since the inspection the Manager has reviewed this risk assessment to include further measures to reduce the level of risk for this resident. Residents commented that staff were caring and would always help them when needed with their care. Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 16 Each resident has a “resident record sheet” that is completed in respect of significant events including when they attended appointments at hospital, with the GP and mental health teams. This record also reflects upon any accidents or incidents. Several residents did comment that staff would help arrange appointments and that they have also attended appointments with them. Risk assessments and care plans were seen for one resident following an accident, these detailed how the accident had impacted on the activities of daily living and how staff will provide support. The home manages all residents’ medicines, including ordering, storage, administration and disposal. The system in use is a monitored dosage system provided by a High St chemist. All medicines are recorded when received into the home and checked against copies of the GP’s prescriptions for accuracy. Some residents are prescribed “as required / PRN” medicine; for this the home has written a protocol to provide staff with a guide about when it should be administered. One resident does apply prescribed cream and ointments personally and the resident is regularly asked if they have been applied. There are photos of residents with the medication administration records and any allergies are recorded. All staff that manage medicines are required to undertake training, at present seven staff are studying the safe handling of medicines course at college. Whilst checking the stock of medicines for one resident it was found to be inaccurate, the medication administration record had been signed to confirm that medicines had been administered when they remained in the blister pack. Some residents do receive injections from mental health teams, although the staff do not administer the injections it is recommended when it is next due be recorded on the medication administration record. Radnor House DS0000016871.V308869.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home does demonstrate it has the resources and processes to effectively manage complaints and protect vulnerable residents. The residents have confidence the staff will act in their best interests. EVIDENCE: Those residents who spoke with the inspector did not have any complaints to make. The surveys returned on behalf of residents indicated that all residents know how to make a complaint. One resident had raised concern that some money had gone missing, this was checked at the time of inspection; the manager had fully documented these concerns and taken all appropriate actions, including involving external healthcare support and developing care plans and risk assessments. The resident was seen at the time of inspection and was not concerned about money. The home does have a complaint log; no complaints had been recorded since the last inspection. The Commission has not received any complaints about the home in the past twelve months. The pre-inspection questionnaire (PIQ) indicated that the policy about protecting vulnerable adults was still in place and had not been amended; its last review was in March 2006. The staff-training matrix indicates that four of the staff have attended more formal abuse awareness training, and a statement made by the manager attached to the PIQ declared that internal training had included abuse awareness (the manager holds a teaching certificate). The home does provide a safekeeping service to help support residents to manage their money, at the last inspection all but four residents had been able to open accounts with the post office or bank. These four Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 18 residents still have money paid into a zero interest account in the name of the home; the manager advised that a risk assessment has been implemented to ensure it is at all times safely managed and also how residents are able to access their money. Residents commented that their money was safe and that they can get it when they need it. Accounts were seen and found to be accurate with balances and outstanding receipts. Radnor House DS0000016871.V308869.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,27 and 30. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has not adequately demonstrated it has the ability to fully meet the environmental needs of residents as some areas are not fit for purpose or unsafe, which may put the health and safety of residents at risk. EVIDENCE: The manager advised at the last inspection that a programme of refurbishment had been developed and that the next phase was to replace the flooring in many of the bathrooms and toilets, as yet this has not been completed. Residents have been consulted about the facilities and furnishings communal and in their rooms and have not raised any concern. However there are some communal areas where the furniture is not adequate including seating mainly armchairs and some dining room chairs that are damaged and need to be replaced. The garden is large and kept tidy, there are some damaged fence panels where temporary support has been made; the manager advised that he has been in discussions with the neighbours and hopes the repair will be completed shortly. The majority of other furniture and fittings in communal areas are older in style and fit for purpose, the manager will need to audit all Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 20 communal areas including the upstairs lounges, of which one has a snooker table to ensure they do remain fit for purpose. The laundry is sited away from any food storage or preparation areas and has a washing machine with a sluice cycle and two tumble dryers, the flooring is linoleum and in good condition. The area is very dark and lighting needs to be improved, especially late in the day to ensure staff and residents can see what they are doing and ensure the laundry is kept clean. Some residents do have clothing and bedding that requires a sluice cycle and alginate bags are provided to improve infection control. There is a large sink used as a handwashing basin and soap was available, there were no facilities to dry hands. There is a clinical waste contract with bags and containers and a facility for sanitary disposal. The majority of residents indicated in the survey that the home was kept fresh and clean. The door to the laundry would not close into its rebate. Radnor House DS0000016871.V308869.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staffing 32,33,34 and 35. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has been able to demonstrate that staff are available at present in adequate numbers to meet the needs of residents, that they have a good knowledge of the needs of residents and are safely recruited. Yet there is some concern that staff are not being effectively trained to maintain safe working practices and to meet the specific mental health needs of residents. EVIDENCE: The residents who spoke with the inspector were positive that the staff were skilled and competent to do their jobs. All residents who returned the survey believe that the staff will act on things they say and they also confirmed that staff treat them well. The staff who spoke with the inspector appeared to have a good understanding of the needs of residents and were seen purposefully interacting with many residents whilst always respecting their individual choices. The pre inspection questionnaire recorded that ten out of the eighteen care staff had completed the NVQ level 2 award. Two residents reported that there are usually enough staff on duty and the staff duty rotas also indicated there are at present adequate numbers of staff on duty. This will need to be reviewed should the needs of residents change. At present there are twenty-six residents, who are normally supported by Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 22 three care staff during day hours and two at night. In addition the manager and deputy work full time covering the weekend, however the actual hours they work is not recorded on the rota. There is a full time cook and a part time cook. The rota does record domestic hours but does not record any staff names, however at the time of inspection a member of staff was seen undertaking domestic duties. The recruitment practices at the home as of the last inspection were assessed as being safe to protect residents. There have been no new staff appointed since the last inspection. The training matrix provided by the manager did not refer to induction standards based upon skills for care as their have been no new staff. The inspector was advised that the matrix was not fully up to date however it was evident that a programme of training is in place. The training providers are from a variety of establishments, including colleges, companies, training organisation and also by the manager. Some staff are currently on the following courses, NVQ, Health and Safety and Medication. There are gaps in the following areas of safe working practice training first aid, food hygiene and fire safety; with fire safety being a concern. Many staff have received patient handling training, some in excess of three years and refreshers are needed, with regard to the same training it is recorded that recent training has been conducted at the home, yet it is not evident that there is a person who is able to train staff. The training matrix did not record that staff are receiving training in respect of the specific needs of residents such as Mental Health Awareness. The managers training profile does not appear on the matrix. Radnor House DS0000016871.V308869.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has partially demonstrated that it is well run in the best interests of the residents, it is evident that day to day management and health and safety are well managed however the opinions and views of residents are not entirely sought and acted upon. This may institutionalise how care is provided for residents. EVIDENCE: The residents who spoke with the inspector expressed a sense of friendship when they spoke about the manager. On many occasions they were seen speaking to him in communal areas of the home and some who returned from their daily activities came to his office to speak with him. It was evident he had a thorough knowledge of their needs, care plans and abilities and often in conversation referred to improving their living skills. Staff also felt that they were well led and could approach him about professional and private issues. Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 24 The manager advised that the residents continue to meet as a group on a regular basis and often discuss important issues related to the services they receive. Minutes of the meetings are available and concur with this. Resident’s views and opinions are often sought where they wish to participate in care plan reviews and where possible changes to their care are made. The manager advised that although no formal audits and a quality report had been made this year he had looked at other processes that he could implement and plans to do this very shortly. The home maintains thorough records relating to health and safety of equipment, premises and utilities. It was evident the fire system and equipment is regularly tested, serviced and a fire risk assessment is in place. Fire drills are conducted frequently and staff and residents take part, outcomes and any concerns are recorded and improvements are planned. The last and recent fire officers report required the home to make improvements, some have been completed and others are in the process. Risk assessments for safety in the building, food and staff are in place, some are now in need of a review. Electrical (including appliances), gas and water utilities are frequently tested and have been certified as safe. Radnor House DS0000016871.V308869.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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Radnor House DS0000016871.V308869.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 YA17 Regulation 12(1) 17(1)(a) Requirement The registered manager must ensure that where records are to be maintained to help assess a resident, such as dietary intake that these at all times are fully completed. The registered manager must ensure that residents are always given their prescribed medication. The registered manager must ensure all staff are provided with adequate training to protect vulnerable adults. The registered manager must provide a programme of refurbishment to the Commission and complete the necessary work. This must include replacing damaged and unfit flooring in bathrooms and toilets. Timescale for action 30/11/06 2 YA20 13(2) 30/11/06 3 YA23 13(6) 18(1)(c)(i) 31/12/06 4 YA24 YA27 23(2)(b)(c) 31/01/07 Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 27 5 YA24 23(2)(b)(c) 6 YA24 7 YA24 8 YA30 9 YA33 10 YA35 11 YA39 The registered manager must audit all furniture and fittings in the home to inform the audit process and replace furniture and fittings that are no longer fit for purpose. 23(2)(p) The registered manager must ensure that lighting in the laundry area is improved. 23(2)(b)(4)(c)(i) The registered manager must ensure that the laundry door is repaired allowing it to fully close into its rebate. 13(3) The registered manager must ensure that good hand washing facilities are available in the laundry. 17(2) Schedule The registered manager 4(7). must ensure that the duty rota records the hours worked by all the staff in the home including domestics and managers. 18(1)(c)(i) The registered manager must ensure that all staff do receive all required training in safe working practices and also are trained to meet the specific needs of residents including Mental Health Awareness. 24 The home must develop and audit a system of Quality Assurance. Previous timescale of 31/8/05 not met, this requirement has been carried forward. The registered manager must ensure that the requirements made by the fire officer at his recent inspection are completed within timescale. DS0000016871.V308869.R01.S.doc 31/12/06 30/11/06 30/11/06 30/11/06 30/11/06 31/01/07 31/01/07 12 YA42 23(4) 30/11/06 Radnor House Version 5.2 Page 28 13 YA42 13(4), 12(1) The registered manager 31/12/06 must ensure that health and safety risk assessments are regularly reviewed. 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 YA20 Good Practice Recommendations It is recommended that the staff record when depot injections for residents are next due to be given by the mental health team, preferable on the MAR. Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. Extracts may not be used or reproduced without the express permission of CSCI Radnor House DS0000016871.V308869.R01.S.doc Version 5.2 Page 30 - 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. 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