Inspection on 12/07/05 for 11 Station Road

This inspection was carried out on 12th July 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

11 Station Road 04/09/07

11 Station Road 12/02/07

11 Station Road 14/12/05

11 Station Road 22/02/05

11 Station Road 10/08/04

11 Station Road 15/03/04

11 Station Road 12/08/03

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 Station Road 11 Station Road Kings Norton Birmingham B38 8SN Lead Inspector Kerry Coulter Announced 12 July 2005 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 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 Stationary 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. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Station Road Address 11 Station Road, Kings Norton, Birmingham, B38 8SN 0121 459 8889 0121 459 8149 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sense West Vacant Care Home 9 Category(ies) of Learning Disability , Physical Disability, Sensory registration, with number Disability (9) of places Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The minimum number of suitably qualified and competent staff throughout the waking day is 7 per shift. 2.The shift pattern incorporates a handover period to enable an exchange of information between staff. 3. Minimum night staffing levels are 4 suitably qualified and competent staff who will be awake throughout the night. 4. The manager is supported by 3 deputy managers, each with responsibility for 2 flats. 5. Care staff are generally assigned to specific flats. 6. Service users must be aged under 65 years. Date of last inspection 22 February 2005 Brief Description of the Service: 11 Station Road is a registered care home, owned and managed by Sense, which is a voluntary organisation supporting people with dual sensory impairment and associated disabilities. It is located in Kings Norton, Birmingham and is close to a variety of shops, public transport and community facilities. The home comprises of 3 flats with two bedrooms, and 3 flats with one bedroom. All flats are self-contained and each bedroom has an en-suite bathroom. The home also provides a communal lounge and kitchenette and a separate laundry room. There is a small staff office on the ground floor and a staff sleep in room, which is currently also being used as a working office on the second floor. There is a large communal bathroom on the ground floor, which would be suitable for someone with additional physical needs. The current service users do not use the bathroom. There is a large, landscaped garden to the rear of the building with features to aid access for deaf blind people. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over one day. Conversations with service users were limited due to their complex needs and limited verbal communication abilities. However, the inspector was able to spend time with many of the people who live at the home observing care practices, interactions and support from staff. A partial tour of the building was made. Flat 3 was not observed. Care plans and risk assessments were inspected. Staff training and recruitment procedures were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the Assistant General Manager, Practice Development Worker, agency staff and informally to support workers. Information has also been obtained from the pre inspection questionnaire completed by the Assistant General Manager prior to the inspection. CSCI comment cards had not been received from relatives, care managers and health and social care professionals at the time of writing this report. What the service does well: What has improved since the last inspection? A new format for Health Action Planning has been introduced recently. Work has commenced in seeking to identify and systematically record individuals’ health needs. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 6 What they could do better: 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. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 8 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 standard(s) 1 The Service User Guide and Statement of Purpose do not provide clear information for prospective service users to be clear about the services the home provides to meet their needs. EVIDENCE: Previous inspections have identified that the statement of purpose requires owner/provider details; the service user guide must include a standard form of contract/terms and conditions. The service user guide must be made available in a format to meet the needs of the service users who live at Station Road. The General Manager said that a steering group was working on a new statement of purpose and that a service user guide that includes photographs was in development. These documents need finalising to ensure service users and their representatives have all the information they need to make an informed choice about where to live. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 9 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 standard(s) 6, 7 and 9 The care planning system in place does not adequately provide staff with the information they need to satisfactorily meet service users needs. The arrangements to support service users to make choices and decisions about their daily lives and routines were variable. EVIDENCE: Five care plans were sampled. The standard of the care plans sampled across the flats was variable but a common theme was that often care plans were not signed or dated. It was therefore not possible to determine that the care plans had been kept under regular review. SENSE as an organisation expects that each service user will have a monthly review attended by the core team of staff that supports that person. Minutes were not always available on a monthly basis of these review meetings. In one flat the care plan of one service use needed significant development. The section on daily living skills was blank and there was no adequate information as to how the cultural needs of the person would be met. These must be completed to ensure staff are aware of the support required and a consistent approach is provided. There was insufficient evidence of how the “goal” and “aspiration” section was put into practice for some individuals. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 10 Guidance for staff in care plans is not always followed. For example, the care plan for one individual recorded that each member of staff working with him must wear a personal symbol. Only one of the three staff in that flat was observed to have a personal symbol. This could result in a service user being unaware of the staff that are working with him, this would not be a pleasant experience for the individual. In some flats the daily records were often not signed or dated, and there was insufficient evidence of how choices are offered. There was no detail of the individual’s response to care given. The activity sections on the daily record sheets were frequently not completed. Whilst improvement is needed to records across the flats it is acknowledged that generally the care plans and daily records in flat 5 were of an acceptable standard. Evidence was available that other professionals are involved in the care of people who live at the home, for example the Speech and Language Therapist has completed assessments for eating and drinking. Some work is required on risk assessments to ensure that they are up to date, reflect individuals’ current support needs and detail all the control measures in place. Each risk assessment should be directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other. One of the outcomes for completing risk assessments and care plans should be that the finished article is a simple and effective working document, in which essential information can be easily found. Not all of the assessments sampled had been recently reviewed and some were not satisfactory. For example a risk assessment for rock climbing directed staff to read the risk assessment located at the rockclimbing venue. This is not satisfactory, as staff would need to be aware of the risks before arriving at the venue to include staff ratios and training. The level of risk needed to be made clearer within the assessments sampled. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12, 13, 15, 16 and 17 A range of activities is offered in order to promote personal development, participation in the life of the local community and enjoyable leisure time but too many planned activities are cancelled. Service users enjoy a healthy and nutritious diet but the cultural needs of people needs to be reflected in the meals offered. EVIDENCE: Each person who lives at the home has a timetable of daily activities. The activities on offer include swimming, rock climbing, visits to parks, meals out, art and music activities, ice-skating and cooking. Whilst the activities are varied discussions with staff and sampling of records indicate that sometimes the planned activity does not take place. This was of particular concern in flat 1 where activities had not taken place due to ‘no driver on duty’, ‘did not go swimming because flat 2 not going’ and ‘not enough money to go out’. A full review is needed to clarify why activities are not taking place and to ensure the amount of cancelled activities is reduced. The amount of drivers available needs to be increased or alternative transportation arranged. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 12 The service users contribute a set monthly amount from their mobility allowance to the running costs of the minibus. In light of the lack of drivers this arrangements must be reviewed. The service users must be offered value for money and an equitable system. As previously highlighted recordings in the daily records were poor. Some recordings stated “went out” there was no details of where too, or the persons response to the activity. The home has a visitor’s policy and actively encourages visits from family and friends. There was evidence that relatives also have contact by the telephone and letters /cards. Where staff use the home’s transport to take individuals to visit their family the care plan contains directions from Station Road to the relatives home. This enable any new member of staff to be clear about where they are going and reduces the potential of getting lost. It is an area of good practice that SENSE employs a Family Liaison Officer; she had been involved with relatives in the process of the new admission to the home. Additionally, a family weekend is also arranged at a local hotel where relatives can meet with SENSE representatives and other relatives. A mealtime was not observed. Menus supplied with the pre inspection questionnaire and records of food sampled showed that in general people who live at the home are offered varied and nutritious meals. However for one individual in flat 4 there was no evidence that cultural or religious needs had been taken into account when planning the menu. Staff spoken with were unsure of what his cultural needs were and were uncertain as to what should be offered. This needs further exploration. Discussion with staff indicates that meal times are flexible. Choice was observed to be offered during the inspection, one individual chose to have his lunch in the garden supported by a member of staff. Kitchens were observed to have adequate supplies of food. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19 and 20 Arrangements for healthcare are variable with particular attention deeded in respect of monitoring and staff guidance. The systems for the administration of medication require improvement to ensure service users medication needs are met. EVIDENCE: A new format for Health Action Planning has been introduced recently. Work has commenced in seeking to identify and systematically record individuals’ health needs. This should now be built on so that the document moves from being a statement of need to a planning and monitoring tool. Further work needs to be done to ensure that where individuals are identified as being at risk from epilepsy clear guidelines are available for staff. These should include descriptions of a seizure and the action staff must take in the event of a seizure occurring. Some health monitoring records were not up to date. For example the care plan recorded that one individual should be weighed monthly, but this had not been recorded since November 2004. Where individuals are unable to fully communicate their well being regular weight monitoring is important as weight gain or loss can be a sign that a person is unwell. Discussion with the General Manager and observation of the homes training matrix indicates that not all staff have received accredited medication training. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 14 The home has had difficulty accessing training and is awaiting places for some staff. However, medication competence assessments are completed for all staff who administer medication. In some flats the medication administration systems were of a good standard but some improvement was required in other flats. In flat 4 two tubes of ointment had been opened for one individual, it is good practice to have only one tube open at a time. The tubes had not been dated on opening. This is required and the ointment should then be discarded 28 days after opening. In flat 6 records were observed on the use of ‘as required’ medication for one deaf/blind person that were used for behavioural reasons. The standard of recording was variable and whilst some staff had completed satisfactory records many entries did not record if the medication had been effective. Effective recording is essential to establish if the medication is making a difference, its use can then be properly reviewed. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 15 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 standard(s) 22 and 23 The home has a satisfactory complaints system. Physical intervention and adult protection training is lacking for some staff and impacts on the homes ability to ensure that service users are being protected from abuse and that their welfare is being promoted. EVIDENCE: The homes complaint procedure now includes information on the role of the CSCI in investigating complaints. Some of the service users due to their complex needs are not able to make a complaint and are reliant on staff, relatives or an advocate to act on their behalf. CSCI were formally notified of an internal investigation in the home. A hearing of the matter is pending. When the outcome is known the CSCI must be informed. The home recently informed the CSCI and Social Care and Health of an adult protection incident concerning physical intervention. It was agreed that this would be investigated by SENSE who have appointed a manager external to the region to investigate this matter. The investigation was not concluded at the time of the inspection. The challenging behaviours of two people living at the home had escalated. CSCI have been informed of incidents where physical intervention had been used. Records on the use of physical intervention were sampled, these were found to require improvement. Some records were very detailed but others did not record the length of the intervention, why it had been used and sometimes it was not recorded if the individual had been examined for any injuries following the intervention. Records sampled did not evidence that all staff working with these two individuals had received adequate training in adult Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 16 protection, managing challenging behaviour and physical intervention. This is of concern as it potentially puts both the service user and member of staff at risk. Staff recruitment files were sampled. For one member of staff there was insufficient evidence of SENSE obtaining a CRB check. The recruitment records need improvement to evidence that the right people are working with service users, ensuring their protection. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 17 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 standard(s) 24, 29 and 30 Some fixtures and fittings require replacement to ensure the home presents as a homely and comfortable environment for the people who live there. Standards of hygiene need to improve to ensure there are effective infection control measures in place and ensure the well being of service users and staff. EVIDENCE: Five of the six flats were examined at this inspection. The flats at Station Road were observed to reflect the individual tastes of the people who live there. Although the flats accommodate only one or two people some were quite small in size, particularly in regard to size of kitchens and living/ dining rooms. Discussion with staff indicated that the lack of space in flat 6 had caused problems when trying to effectively manage the behaviours of the two individuals who had lived there. The flats share a communal garden; this was observed to be a pleasant and well-maintained area. The standard of décor throughout the flats was generally satisfactory but some minor repairs were observed to be required. Flat 1. The seal around the bath was mouldy in places and requires replacement. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 18 Flat 2. En-suite, some resealing around the tiles required. Flat 4. Lounge carpet stained, this requires deep cleaning to remove stain or must be replaced. Nets at the window were quite tatty with several missing hooks. Flat 5. Lounge carpet stained, this requires deep cleaning to remove stain or must be replaced. The sofa’s are worn and will require replacement. The General Manager acknowledged that some carpets required replacement. She stated that new carpets were planned to be fitted soon, commencing with the communal area. Suitable adaptations have been made to the home to ensure it meets the needs of individuals with a sensory impairment. This includes objects of reference attached to doors so individuals know where they are in the home. Most areas of the home were observed to be clean but some infection control issues require improvement. In flat 4 the temperature of the fridge and freezer had not been monitored for some weeks. This must be done daily to ensure food is stored at an appropriate temperature. Staff meetings recorded that the flat had no thermometer, it is disappointing that no action had been taken to resolve this. The cooker was dirty and required cleaning and the freezer required defrosting due to the build up of ice. In flat 2 cleaning under the microwave was required where there was a large amount of food debris. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 Current staffing arrangements are at times failing to meet the needs of all service users. EVIDENCE: The home has some staff vacancies, these are being covered by staff working extra hours and the use of casual/ agency staff. Discussion with staff and sampling of records indicates that sometimes activities do not take place due to a lack of driver or the ratio of agency staff on duty. It is essential that vacant posts are recruited to, to ensure the people who live in the home are supported by a consistent staff team who are able to meet their needs. At the time of the inspection there were no service users living in flat 6. Examination of the rotas and discussion with staff indicate that the home previously had difficulties in staffing this flat. Some incidents of challenging behaviour had resulted in serious staff injuries and it had proved difficult to staff the home with appropriately trained members of staff. At one point staffing in the flat reached crisis point with a shift being covered by an agency manager and SENSE’s behaviour specialist. It is disappointing that the staffing situation had to reach such a crisis before action to resolve the situation was taken. As the flat is temporarily vacant until one service user returns home, staff previously allocated to flat 6 have been deployed elsewhere in the home and this has reduced slightly the use of agency staff. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 20 Some improvement in staff ratios has taken place. Discussion with the General Manager indicates that extra funding has been agreed for one individual. Staff recruitment files were sampled. The majority of these contained all the information as required by regulation but one file did not contain satisfactory evidence that a CRB check had been obtained. Sense as an organisation has a rolling programme of training. Home managers apply for places on training courses with the training co-ordinator. The training matrix for the home indicates that staff have not received all the required training, to include refresher training. Outstanding training for some staff includes fire, adult protection, physical intervention, challenging behaviour, medication, first aid and food hygiene. Discussion with staff indicates that it has previously been difficult to secure training places but that this has improved with more training being planned. Discussion with the General Manager indicates that the behaviour specialist will be organising physical intervention/ managing challenging behaviour training to improve this area of staff development. Staff supervision records were sampled for staff who had worked in flat 6. Whilst staff had supervision at a frequency of a minimum of six per year there were periods in early 2005 when staff had gone several months without formal supervision. Given the level of challenging behaviour occurring in the flat at this time supervision should have been arranged on a frequent basis to ensure staff were appropriately supported during this difficult time. There was however, some evidence that the frequency of supervision had improved with the introduction of an agency manager to the flat. It was discussed what opportunities were available for casual staff to have supervision. The General Manager stated that some casual staff did get supervision but that the organisation had no set guidelines for this. Given that some casual/ agency staff work in the home on a very regular basis a structure for formal supervision should be introduced. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 42 The home had not been adequately managed. The health, safety and welfare of the service user had not been adequately promoted and protected. EVIDENCE: This is a very complex service requiring strong leadership. The home has not had a registered manager for several months. At the previous inspection the three managers responsible for two flats each (formally deputy managers) told the inspector that they feel that they need greater support from senior management. Since then a General Manager has been overseeing the home and an agency manager has been covering flat 5 and 6. In spite of these improved arrangements it was evident that management arrangements were still inadequate and did not ensure the home was being managed effectively. In response to matters raised the General Manager stated that a new manager had been recruited and was due to start soon; an application must be made to the CSCI for registration. Some issues of health and safety required attention. As stated earlier in this report some staff had not received adequate training in physical intervention. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 22 This lack of training is of concern as it potentially puts both the service user and member of staff at risk. Notifications received by the CSCI recorded some injuries to staff. Refresher fire training for staff was required. It was observed that some doors in the home were not fitted with a smoke seal; a requirement was made for the home to consult with the West Midlands Fire Service on the issue. In one flat there was no evidence that staff were monitoring water temperatures. This must be done on a regular basis to ensure that the water is at a safe temperature and does not pose a risk of scalding to deaf/blind people. In flat 4 several staff meeting minutes covering a period of some months made reference to a new cooker being required as the one is use was dangerous. It was unclear why it was dangerous but there was no evidence of any action being taken to replace/ repair the cooker. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x 3 2 Standard No 11 12 13 14 15 16 17 x 2 2 x 4 3 2 Standard No 31 32 33 34 35 36 Score x x 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Station Road Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score 1 x x x x 1 x E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4. Schedule 1 (2)5.(1)(c )Schedule 4 Requirement The statement of purpose requires owner/provider details. The service user guide must include a standard form of contract/terms and conditions. The service user guide must be made available in a format to meet the needs of the service users who live at Station Road. Outstanding requirement from 30/10/04. A copy of the contract must be made available on the service user file. It must include all the required information as detailed in the National Minimum Standards. The service/user manager must sign it. Requirement not assessed at this inspection and carried forward. Care plans must be signed, dated and reviewed at least six monthly. The care plans must detail how any cultural needs will be met. Any guidelines in place must also be kept under review. In line with individual care plans staff must wear their personal identification symbols when on duty. Daily records must include Timescale for action 30/10/05 2. 5 5 30/10/05 3. 6 15 30/9/05 4. 6 12(1) & 15 12(2) 30/8/05 5. 7 30/8/05 Page 25 Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 6. 9 13(4) 7. 12 & 13 12(1)(b) 16(2) 8. 9. 17 19 12(1) & 15 12(1)(2) 10. 19 12(1)(2) 11. 20 13(2) 12. 13. 20 20 13(2) individuals response to care and how choices have been made. Ensure risk assessments are completed for all areas of identified risk. The risk assessment must include all control measures in place, level of risk and be cross referenced to the care plan and vice versa. Risk assessments must be reviewed at least six monthly or sooner if a critical incident occurs. Service users must be offered a choice of activities. The amount of cancelled activiities must be reduced. Opportunites must not be restriced because of transport issues. Menus must be reviewed to ensure service users are offered culturally appropriate meals. Guidelines are required to be completed where deaf/blind people are at risk of epilepsy. These should include, descriptions of a seizure and the action staff must take in the event of a seizure occurring. Health monitoring records must be kept up to date. Where individuals are assessed as needing to be weighed monthly this must be done, or a record made that the individual has declined to be weighed. All members of staff who administer medication must receive accredited training. Outstanding requirement Topical creams and ointments must be dated on opening and discarded after 28 days. The standard of recording must be improved when as required medication is administered to record the effectiveness of the medication. 12/08/05 30/08/05 30/08/05 09/07/05 300/8/05 30/9/05 30/8/05 30/8/05 Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 26 14. 23 & 35 12(1) & 13(6) 15. 16. 23 24 12(1) & 13(6) 23(2)(b)( d) 17. 30 16(2)(j) &23(2)(d) 18. 30 16(2)(j) &23(2)(d) 19. 20. 21. 33 34 35 18(1)(a) 7,9,19 schedule 2 and 4 18(1)(c ) The use of physical intervention must be in line with current good practice and Department of Health Guidelines: Records on the use of physical intervention require improvement and staff must receive satisfactory training to include yearly refresher training. All staff must receive adult protection training. A planned schedule for maintanance/ replacement of fixtures is required: Flat 1. The seal around the bath was mouldy in places and requires replacement. Flat 2. En-suite, some resealing around the tiles required. Flat 4. Lounge carpet stained, this requires deep cleaning to remove stain or must be replaced. Nets at the window were quite tatty with several missing hooks. Flat 5. Lounge carpet stained, this requires deep cleaning to remove stain or must be replaced. The sofas are worn and will require replacement. Infection control practice requires improvement to ensure kitchen appliaces are kept clean and freezers defrosted on a regular basis. Fridge and freezer temepratures must be monitored on a daily basis with a record maintained to ensure food is stored at a safe temperature. The home must appoint to vacant posts. The home must have the required staff records available in the home. Staff must receive training in all mandatory areas. A training plan must be forwarded to CSCI. 30/08/05 30/09/05 19/09/05 30/08/05 19/07/05 Immediate requiremen t 30/09/05 30/08/05 19/09/05 Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 27 22. 36 18(2) 23. 37 18(1)(2) 24. 42 13(4) & 23 25. 42 13(4) & 23 13(4) Formal supervsion must be provided to staff at an appropriate frequency, once every two months. Review the current management arrangements to ensure each flat is effectively managedand staff have appropriate support and supervision. Consult with the West Midlands Fire Service regarding fire doors, action must then be taken in line with the outcome of the consultation. Ensure all staff receive fire training at least six monthly. Staff meeting minutes record that the cooker in flat 4 is dangerous. Risk assess and purchase new cooker if required. Ensure water temeperatures are monitored on a weekly basis to ensure temperatures are at a safe level, 43C. 30/09/05 19/07/05 Immediate requiremen t 19/07/05 Immediate requiremen t 12/08/05 Immediate requiremen t 15/07/05 Immediate requiremnt 19/07/05 Immediate requiremen t 26. 42 27. 42 13(4) 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 36 Good Practice Recommendations Considertion should be given to improving systems of supervision for casual/agency staff. Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Birmingham & Solihull Local 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 Station Road E54 S41220 Station Road V232935 120705 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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