Inspection on 05/04/06 for Strensham Hill

This inspection was carried out on 5th April 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Strensham Hill 20/08/09

Strensham Hill 19/08/08

Strensham Hill 20/02/08

Strensham Hill 10/05/07

Strensham Hill 11/10/06

Strensham Hill 12/10/05

Strensham Hill 27/04/05

Strensham Hill 11/11/04

Strensham Hill 24/05/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Strensham Hill 1 Strensham Hill Moseley Birmingham West Midlands B13 8AG Lead Inspector Sean Devine Unannounced Inspection 5th April 2006 08:30 Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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 Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Strensham Hill Address 1 Strensham Hill Moseley Birmingham West Midlands B13 8AG 0121 442 4580 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) enquiries@servolct.org.uk Servol Mark Daniels Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years That the home can care for named service user over 65 years for reason of Mental disorder 1 MD(E). That the service user will have regular reviews to ensure that the home can continue to meet individual care needs. 12th October 2005 Date of last inspection Brief Description of the Service: The home is a large house on the corner of Strensham Hill Road. It is close to local amenities such as shops and places of worship. Moseley is also within easy reach. Cannon Hill Park, where there is a range of facilities, is also within easy walking distance. Within the home residents have their own rooms, and there are communal living and kitchen areas, as well as a self contained flat which provides an opportunity for more independent living. The main lounge is bright and airy, and faces on to Strensham Hill. The kitchen is to the rear of the property and has individual storage facilities for each resident. There is a garden to the rear of the property, which is private, residents make good use of it in the summer months. To the rear of the garden there is space for some car parking. The home is geared towards providing rehabilitation to residents with enduring mental health issues with a specific focus on the needs of AfroCaribbean residents. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was the first unannounced visit to the service as part of the 2006 to 2007 regulatory activity. The inspector was able to meet with most residents, staff and the manager. Records pertaining to care, services and health and safety were viewed and an escorted tour of the premises including some residents’ accommodation was undertaken. Following the inspection visit a letter of serious concern was issued to the responsible individual in respect of care planning, residents risk assessments and recruitment of staff. What the service does well: What has improved since the last inspection? Residents have access to a statement of purpose detailing what the home provides, this includes staffing, services, important policies and what resources are available. This helps the resident make a decision on whether they would like to live at the home. Residents have access to a complaints policy, it contains relevant information about how to raise concerns and the different ways these concerns can be managed. The kitchen has been totally refurbished, including new flooring, splash back tiles, new work surfaces and cabinets; the dining area has had the old tables and chairs replaced. One resident commented “its good to have a nice kitchen”. Risk assessments for staff, food and the premises have been further developed to include how risks in these areas can be reduced. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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 the following standard(s): Standards 1, 2 and 5. The residents are provided with some important information about the home to help them make a decision about living there. The staff receive pre-admission information to help them decide on whether they have the abilities and resources to meet the needs of the proposed new resident. EVIDENCE: There is a statement of purpose available to residents and other interested parties. This document is available in the hallway, and records of residents meetings indicate they have been invited to have their own copy. The statement of purpose includes important information for example, details of services, facilities, copies of important policies and staffing information. No residents’ guide is available. Of the six residents two of their care files were sampled. Both contained information that was available to the home prior to admission. This included CPA summaries, reviews and care plans, information from the social worker and psychiatric reports. A referral application is completed by the referring agent, who is normally a social worker which provides current information about the care needs and any risks associated with the resident being referred. Servol staff also attend where possible pre-discharge case conferences for possible new residents. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 9 Residents are provided with a contract detailing terms and conditions of living at the home, it includes their room, how much must be paid and residents had signed those seen on their files. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 and 9. Staff are not fully informed of the care needs, choices and associated risks of residents, they are not always aware of what they must do, this may mean that residents do not always receive the support they require. EVIDENCE: One resident had a detailed individual plan of care, which had been developed from a detailed assessment. These were seen to be available for most areas of daily living, including education and work, finances, culture and social and recreational support. One care plan indicated that the resident needed assistance with personal care, however it was not specific and did not instruct staff in what they must do to meet the aims and objectives of the care plan. This file included a detailed activity plan, which is reviewed with the resident on a monthly basis and encourages, independency, recreation and domestic and social activities. All care plans on this file were agreed with the resident and where possible personal choices had been incorporated into the care plan, for example which hairdressing salon the resident wished to go to. Several residents commented they are able to make decisions on a daily basis about their lives and that their personal choices are not normally challenged by staff at the home. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 11 The file for a recently admitted resident contained details in CPA documents relating to the care needs and risks presenting for this resident. It was a serious concern that this resident had been at the home for four weeks and no health care plans or risk assessments had been formulated by the home to meet the needs and risks identified. Visits made by the community psychiatric nurse and other agencies and professional had not been recorded. On one residents file risk assessments had been developed detailing what the risk was, what increased the risks and what reduced the risks, these had been completed and included mental health, abuse, physical health, self care and housing and life skills. It was not clear in the mental health risk assessment what the relapse indicators are and what staff must do should they be apparent. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13 ,15, 16 and 17. The residents’ lifestyle needs are met, their personal choices and preferences are encouraged and included in plans. Residents feel they are supported to live respectfully and as independently as is possible. EVIDENCE: Residents informed the inspector that they are encouraged to develop and maintain life skills such as communication and domestic training at the home and also at day centres, this was confirmed on activity plans. Residents confirmed that they attend day centres where they are able to take part in IT, history, literacy and numeracy classes and also music, which they particularly enjoy. Again this can be evidenced upon activity plans and in some daily records. The manager advised that the new computer is being used by some residents, which has all activity monitored for safety and security reasons. Minutes of residents meeting and in talking with residents it is clear that they access many of the local amenities and also those further a field. Local shops are used and also shops and cinemas in the city centre. One resident is being Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 13 encouraged to rekindle her desire for attending church and also to regularly go out for meals. The manager advised that there was not always adequate numbers of staff on duty to fully support this, especially at the weekend. Residents confirmed that they have regular visitors and some described that they go and visit family and friends. One care plan and risk assessment identified the need to re-establish family contacts and to maintain those in place. Residents were seen being given their own post. Staff were seen talking respectfully with residents, even under some difficult circumstances and it is clear staff spend the majority of time with residents. Residents have unrestricted access to all communal areas and their own rooms and were seen frequently in the large communal lounge and rear garden. Staff at all times knocked on doors of residents’ rooms before being invited to come in. One day a week a communal meal is provided, cooked by residents and staff, the menu is decided the day before and choices of meals are topically discussed at residents meetings, this meal is provided by the home. One resident is diabetic and the staff shop and cook for her, a menu record is available and records indicate that further encouragement to eat a healthier diet must be undertaken. At the last inspection it was a concern that some residents diet and nutrition is not adequately monitored and that where risks are apparent risk assessments are not in place, at present the manager advises there are no such risks. Residents have their own lockable storage cupboards, and allocated space in fridges and freezers and clearly have a good supply of fresh, refrigerated and frozen food items. One resident commented that she has adequate money for food. Some residents have their meals up to three times a week at a day centre; they commented that the meals were okay. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 14 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. Residents are supported to access community healthcare services and some are also provided with personal care. Records and care plans are not always fully maintained to provide evidence and instruct staff. Records of medicine administered to residents are not always available. EVIDENCE: One residents care plan indicated that assistance was needed with personal care, however as described in standard 6 it was not clear what support this was. One resident who does require some assistance has an en-suite shower facility to enable her needs to be met safely. One residents file recorded regular visits from the GP, appointments with the dental hospital, and appointments with the optician and regular reviews with the community psychiatric nurses and consultant psychiatrists. It was evident that whilst the manager had been away from the home in the past two weeks that one resident who has had visits from the community mental health team had not had these visits and their outcomes recorded. The medicine management for the two residents whose care plans had been case tracked were assessed. One resident is provided with medicine in a medidose pack delivered by the community mental health team and one is prescribed medicine by a GP and dispensed by a local community chemist. All Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 15 stocks of medicines were found to be accurate. There was concern that the records for the past two days for the resident using the medi-dose system had not been maintained. This medication had been administered but not recorded as so, this was addressed by the manager at the time of the inspection, agency staff had managed these nighttime medication rounds. The manager was advised that he must ensure that staff who administer and manage medicines are competent. The storage of medicine including insulin is good and most permanent staff who administer medicines have completed a care of medicines course. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 16 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. Residents are well supported to raise their concerns and make complaints, they are positive that staff will address them effectively. Residents are not adequately protected from abuse, some staff have not been trained and some risk assessments are not completed. EVIDENCE: Residents have access a full and detailed complaints policy as part of the statement of purpose, this includes a form to advise residents and their representatives of how to make a complaint and what will happen. A complaints book is available, however the last formal complaint was made in 2003. The commission has not received any complaints in the last twelve months. One resident said she speaks to and tells staff if she has any problem and that she has confidence it will be sorted out and at the time of inspection one resident who was upset was supported and was given time by the manager and staff to put across what was concerning her. Sampled staff training records including records for the manager did not record that training in protecting adults from abuse had been received. The manager has in the past contacted the commission when concerned about possible poor practice or a general concern for safety. Two residents have some of their money managed for safekeeping at the home, care plans and risk assessments regarding financial management need to be completed to reflect why this is required. The balance of residents’ money in safekeeping was found to correspond with available records. Five residents have their own bank accounts. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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 the following standard(s): Standards 24, 25, 26, 27, 28 and 30. Residents’ needs in respect of a safe, well maintained and comfortable communal and private areas and facilities are met. EVIDENCE: The premises are well maintained, they are clean and well decorated. Residents are informed of when furniture, fittings and decorations are being replaced. The manager advised that further redecoration of communal areas is planned for September 2006. Two residents rooms were seen with the permission of the residents. One is a large flat, with separate kitchen, lounge, bedroom and bathroom. The other was a large single room with a closet wash hand basin. Storage in both rooms was not adequate for the amount of personal belongings, however plans to streamline these belongings and provide additional storage are in place. Both rooms had comfortable seating, divan beds, wardrobes, chest of drawers and bedside cabinets. The manager advised that paperwork was in the process of being developed to enable a consistent approach to auditing fixtures and fittings in residents’ rooms, thus the requirement at the last inspection to do this has not been completed. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 18 The flat has its own toilet and bathroom and one room has an en-suite shower and toilet facility. There is one communal bath and shower, neither are assisted. The bathroom also houses a toilet. All were seen to be clean and tidy. There are a further two toilets, one upstairs and one downstairs, close to residents bedrooms. There is one large lounge (non smoking) and a dining area in the kitchen, these are focal points of communal activity. There is a large rear garden, which is frequently used by residents and staff, especially on warmer days. The kitchen has been fully refurbished including repainting, new splash back wall tiles, new flooring and new work surfaces and units. Dining furniture has been replaced. The laundry is small, it is clean and the washing machine has a sluicing cycle should this facility be needed. It has a double sink unit, no soap or hand drying facility were available. All other high risk areas have good hand washing facilities. The home has a contract and containers for the disposal of sanitary waste. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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 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): Standards 32, 33, 34, 35 and 36. Residents do not always have adequate numbers of staff available to meet their needs. Staff are not always safely recruited to protect residents and staff are not adequately trained to meet the needs of residents. Most staff are provided with good support through the supervision process. EVIDENCE: The staff were observed to initiate many conversations with residents, they clearly had knowledge of what each individual resident had planned to do. They helped them prepare for going out, shopping, cooking, seeing visiting professionals and with some personal care. It was evident they were good communicators and were interested in the care they provide. The sampled staff training file did not contain evidence that NVQ 2 in Care had been achieved. At present there are two staff on duty from 9am to 10pm to support the six residents, this includes the manager. One day a week there is an additional member of staff, which enables the manager to focus upon management duties. At night there is one member of staff who is available for residents but on a sleeping-in basis. Due to staff sickness and a vacancy some shifts are being covered by agency staff. The names of agency staff did not appear on the staff rota, however the inspector was able to meet with two of them. As recorded in standard thirteen, the manager advised there was not always Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 20 adequate staffing numbers to fully support residents with domestic, social and recreational activity especially at weekends. Staff recruitment files were sampled; one was found to have a Criminal Records Bureau disclosure (CRB) completed in April 2005 by another service when the employee commenced employment with Servol in September 2005. One written reference was available for this employee, this was not completed by the most recent employer. Details recorded on the application form indicated inconsistent information for example, work history did not include the employer recorded on the CRB at the time of disclosure. The sampled training file did include a book to record the induction and foundation development of this employee. Since employment in September 2005 the employee had attended Fire Safety training, no other training in safe working practices or training specific to the needs of residents had been recorded. Other training files indicate that staff receive training in the care of medicines and mental health awareness and some safe working practices such as first aid and infection control. It could not be evidenced that all staff have received or have planned training for safe handling of medication, mental health awareness, protecting residents from abuse and all safe working practices. Records of staff supervision were available and for some staff this is undertaken frequently and with a focus upon their roles and responsibilities. The manager advised that he has had supervision twice in the past five months, with one record available on file, this may not provide him with adequate support. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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 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. Residents are safe and well protected through good health and safety practices in relation to the environment, fixtures and fittings. The residents are supported by an experienced manager who needs to complete current training. A system to adequately inform residents of quality at the home is not in place. EVIDENCE: The manager advised that he is studying the Registered Managers Award, his training file includes Management Proficiency, Interviewing skills, Care of Medicine and Mental Health training. During the inspection the manager was observed leading staff, making decisions and enabling a resident to relax following a period of anxiety and upset. The manager has a clear understanding of the needs of residents with mental ill health and has developed good relationships with the current group of residents. The organisation has provided a computer to enable effective sharing of information for the manager and staff to use. At the previous inspection the manager advised that the Servol organisation was to undertake the Investors in People quality award, he was unable to Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 22 advise of any progress. He also advised of a Health and Safety assessment tool, this was not in place. Feedback about the quality of service is conducted informally during residents meetings and in conversation with residents, yet there is no formal process of audit against a set of quality standards or any report produced to inform residents and interested parties of outcomes. The registered individual has not made available reports of unannounced visits under Regulation 26 of the Care Home Regulations 2001 either to the manager or to the commission. Health and safety checks, service and maintenance of equipment, utilities and premises are routinely completed. Risk assessments for food, staff and premises are available. The manager advised that the fire officer had seen the fire risk assessment and his opinion was that it was a detailed assessment of fire risk at the home. Fire alarms and emergency lights are tested and the fire system is regularly serviced. Staff regularly attend fire drills and all staff have recently attended fire safety training. The manager advised that agency staff are given information about fire safety and any other emergencies, he plans to involve agency staff who are used on a regular basis in safe working practice training to ensure they are aware of important policies. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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 Standard No Score 1 2 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 3 25 3 26 2 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 1 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 1 X X 3 X Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5 Requirement The manager must ensure that a residents’ guide is developed that reflects the service and is fully informative to prospective residents. Timescale for action 30/06/06 2 YA6 15(1) 3 YA6 15(1) 12(1) Previous timescale of 28/02/05 not met, this requirement has been carried forward. Written care plans must 31/05/06 contain specific information about the care needs of residents, e.g. which area of personal care does the resident need support with. Written care plans in 07/04/06 consultation with residents must be developed shortly after admission where there is adequate information to identify a need. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 25 4 YA9 5 YA9 6 YA17 Risk assessments in 07/04/06 consultation with residents must be developed shortly after admission where there is adequate information to identify an area of personal risk. 12(1) Risk assessments 31/05/06 15(1) completed for mental 13(4) health must include relapse indicators and detail what staff must do should these indicators be apparent. 12(1)13(4)16(2)(I) Residents nutritional 30/04/06 needs must be fully risk assessed and include where needed education and support to eat a healthy diet. This includes residents who have a prevalent health condition such as Diabetes. 12(1) 13(4) Previous timescale of 30/11/05 not met, this requirement has been carried forward. The manager must ensure that all staff administering and managing medication are competent and safe to do so. Risk assessments and or care plans must be in place for residents who have money in safekeeping at the home, the risk assessment must detail why safekeeping at the home is needed. 7 YA20 13(2), 12(1) 30/04/06 8 YA23 13(6) 31/05/06 Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 26 9 YA26 13(4)(a)(c) The manager must ensure 30/06/06 the rooms are audited against the National Minimum Standards with regard to required furniture and fittings, any shortfalls must be either addressed or alternative arrangements made. The shortfalls must be included within the homes statement of purpose. Previous timescale of 31/12/04 not met, this requirement is carried forward. The laundry room must have good hand washing facilities, including for example liquid soap and a hand drying facility. The names and hours worked at the home by all staff must be recorded upon the staff rota, including agency staff. Staffing levels must be reviewed should the amount of residents’ increase or the needs of residents change. There must at all times be adequate staff on duty to assist residents to meet their recreational and social needs, which includes weekends. 10 YA30 13(3), 13(4)(c) 30/04/06 11 YA33 17(2) sch 4 (7) 30/04/06 12 YA33 18(1)(2)12(1) 13(4) 31/05/06 Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 27 13 YA34 19(1)(b)(i) Sch 2 (1 to 7) 14 YA35 18(1)(c)(i) Recruitment of staff must ensure that all relevant checks are completed including CRB, two written references (one from the most recent employer) and that any information declared on the application form is explored and any discrepancies investigated and scrutinised. All staff must have received or have planned training for safe working practices and training to safely meet the specific needs of residents such as; 1. Mental Health Awareness. 2. Protecting Adults from Abuse. 3. Safe Handling of Medicines. The manager must receive regular supervision and records must be available. Previous timescale of 28/02/05 not met, this requirement has been carried forward. 05/04/06 30/06/06 15 YA36 18(2) 31/05/06 Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 Page 28 16 YA39 24, 26 The registered provider must make monthly visits, and reports of such visits must be made available at the home. A continuous self monitoring tool, using an objective, consistently obtained and reviewed and verifiable method (preferably professionally recognised quality assurance system) must be introduced. It must involve residents and have an internal audit which takes place at least annually. Previous timescale of 31/03/05 not met requirements are carried forward. 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA18 YA27 YA43 Good Practice Recommendations The home should produce a policy for smoking in the home. The manager should consider redecorating the bathroom, utilising soft furnishings, lighting and décor to elicit a relaxing experience whilst bathing. There should be a business and financial plan for the home and the service, available to CSCI for inspection and reviewed annually. Strensham Hill DS0000016874.V288496.R01.S.doc Version 5.1 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. 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