Inspection on 27/11/06 for Summerfield

This inspection was carried out on 27th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Summerfield 10/04/08

Summerfield 08/10/07

Summerfield 24/04/07

Summerfield 12/06/06

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

CARE HOMES FOR OLDER PEOPLE Summerfield 42-43 Wellington Road Dudley West Midlands DY1 1RD Lead Inspector Mr Richard Eaves Key Unannounced Inspection 27th November 2006 09:30 X10015.doc Version 1.40 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 Summerfield DS0000066864.V319627.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 Older People. 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. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Summerfield Address 42-43 Wellington Road Dudley West Midlands DY1 1RD 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) 01384 239331 Merron Care Ltd Care Home 38 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (8) Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager should source and undertake further training in dementia care. 28th September 2006 Date of last inspection Brief Description of the Service: Summerfield was originally two semi-detached residential properties that have been linked and extended to its present form. The home is registered to provide personal care for up to 38 people with up to 18 places accommodating older people who have dementia, up to 12 places for older people who do not fall within any other category and up to 8 places for people who are over 65 years and have a physical disability. The home comprises of three floors. The basement is used to house the boilers and is also a storage area. The ground floor has a number of bedrooms, two offices, the kitchen, communal areas and hygiene facilities. The first floor accommodates further bedrooms, bathrooms, sluice and toilets. Summerfield Care Home is located near to central Dudley and is situated on a main road, which is also a main bus route. Opposite is the Dudley Leisure Centre, there is a carvery next door and a number of shops are in the local vicinity, a small car park is available to the front of the home. Fees for this home range from £343 - £372 per week. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key unannounced inspection visit this year and also follows two random visits in the interim, it was undertaken by two inspectors from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the inspections undertaken during in June and August, reports from the organisation relating to the conduct of the home, comment card responses from service users and relatives and records including case files, held at the home. The inspection involved case tracking, a full tour of the bedrooms, communal rooms and service areas and provided an opportunity to speak with many of the service users and a small number of visitors. What the service does well: What has improved since the last inspection? There has been general improvement in risk assessments and care planning but these are not well supported by the assessment process which is superficial and uninformative. The home has provided training for some staff in dementia care and have a programme of training to extend this to all care staff. There have been improvements in medication procedures and managing the storage arrangements but there remains a need for further progress such as progressing the planned staff training. Staff were observed to have a good rapport with service users. The meals are well received and choices are provided at each meal time and the provisions for these meals was available for the days meals. The home has commenced training for staff in adult protection procedures. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 6 What they could do better: Serious concerns were expressed during this inspection about the unsafe recruitment and selection practices. The registered providers must take urgent steps to improve their practice to ensure that service users are protected at all times. Policies and procedures are outdated and do not reflect current good practice and should be reviewed to ensure that staff and service users are protected. The information the home provides to prospective service users must be reviewed and updated so that service users have enough information to make an informed choice about whether or not they wish to live at the home. The terms and conditions of residency need to be updated so that service users are clear about the fees they are expected to pay for residency and what is covered by that fee. Service users do not always have a full needs assessment prior to admission and this must be addressed, without an assessment of need it is difficult for the manager to determine if the home can meet the service users needs. Care planning has improved slightly since the last inspection but there still could be improvement with the introduction of person centred planning for service users and including service users the planning process. The administration of medication has improved but there remains improvements to be achieved including monitoring of the storage area, auditing following administration rounds and expanding training to a wider group of staff. The home should expand the range of social and recreational activities and demonstrate that they seek the service users views of what they would like to do. Meals are generally well received but there remain shortcomings in the way meals are served such as lack of aids in use, assistance provided in an institutional way and a lack of attention to detail to ensure all meal choices are made available. The home should ensure that service users receive a copy of the service user guide that includes the complaints procedure and in a format that is suitable to the individual. In keeping with other policies the vulnerable adults policy needs to be reviewed and updated to reflect current good practice. Some aspects of environment remain outstanding such as fitting of bedroom door locks. Because of inclement weather the condition of the gardens was not checked as it is not being used the requirement remains to be checked. A number of new requirements are made including replacement or repair of kitchen service trolleys, ensuring waste bins are always available in the toilets. The staff facility requires improving and personal storage lockers repaired or replaced. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 7 Records of training given should be recorded in such a way that allows for overall audit and progress of achieving the programme of mandatory topics. On this visit it was not possible to establish the homes position in regard to achieving the target of 50 staff with an NVQ at level 2, this was previously achieved but with a large turnover of staff it was not known the current position without checking every individual file. The induction process must be reviewed and amended to ensure it meets with Skills for Care Standards and that staff receive a copy of the GSCC code of practice. The providers must put forward a manager for registration and progress their quality assurance systems including seeking service user and representatives views of the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective service users cannot be assured that they will receive enough information about the home to be able to make an informed choice about living there. Service users do move into the home without having had their needs assessed and as a result cannot be sure the home can meet their needs. EVIDENCE: The Statement of Purpose and the Service User Guide were both examined, both had shortfalls that need addressing in order for service users to have all of the information they need to make a decision about living at the home. Both documents state that they are available in different formats such as large print or audio however these were not available when the inspector asked for them. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 10 Contracts and terms and conditions of residency were also viewed, the home has outstanding requirements to review these documents because they do not provide clear information about the fees service users are expected to pay and those services that are not included. Service users who returned comment cards to the CSCI also indicated that they had not received either a service user guide or a contract/terms and conditions of residency. Three service user files were examined as part of the case tracking process, of those three files seen only contained a needs assessment. This means that service users may enter the home not knowing if their needs will be recognised and met once they are there. Without an assessment it is difficult to plan the individual care that service users require. The home is registered to provide care for people with dementia, some of the staff have received training in dementia care and there are plans to enrol the remaining staff team on this course. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service user cannot be sure that all of their needs will be set out in an individual plan. Generally service users receive the health care that they need. Medication practices within the home continue to improve but further improvement is needed to safeguard service users. Generally most service users agree that they are treated with respect and dignity. EVIDENCE: Service user plans were viewed as part of the case tracking process. It was pleasing to see that all service users had a plan and that the plan generally reflected their needs. The home assesses service users risk of developing pressure sores, falls, malnutrition and moving and handling. It was difficult to tell if these documents are reviewed regularly because the home has recently introduced new paper work. There are still some concerns about the home’s ability to seek timely healthcare for all of it’s service users. For instance one Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 12 service user has lost weight, whilst it can be evidenced the home have monitored this service users weight, they cannot evidence any other actions they have taken to find the cause of the weight loss or in seeking professional advice until relatives bought it to the managers attention. Another service user has been waiting since September to have their needs reassessed by the local PCT. One service user experiences episodes of frustration and can be physically aggressive but there was no care plan detailing how staff were to meet the needs of this particular service user. It was observed that service users are using bed rails to keep them safe whilst in bed, there are risk assessments for this but they are not being regularly reviewed. Medication practices within the home have not improved a great deal since the last inspection, the home was also inspected by the CSCI’s specialist Pharmacy Inspector in September. A number of requirements remain outstanding although two had been met, it was pleasing to see that all omissions in recording are now being accounted for and the home is now recording the temperature of the fridge. This means that medicines will be stored at the recommended temperatures. Work still needs to be done on the medication policy and more staff need to be trained in the “safe handling of medicines”, the manager did inform the inspector that some staff have recently enrolled on a course at Dudley college and are currently waiting for their course to begin. Service users were seen to be spoken to in a courteous manner throughout the day. There is a notice board in the wheelchair storage area where service users can find their mail, unopened, this could prove problematical with some of the service users who have dementia because they do not remember where the board is and some of the service users only move around the home with assistance from staff and cannot freely access their mail. This arrangement may need to be reconsidered. Staff are not trained during induction how to treat service users with respect at all times, this was discussed with the manager at the time of the inspection. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides little entertainment and recreation opportunities and that provided is largely not dementia appropriate. An open visiting policy assists service users to maintain contact with their family and friends. Service users, as they are able, exercise choice and control over their lives. Meals at the home are wholesome and meet the nutritional needs of service users but personal choice is not always made fully available. EVIDENCE: The home has a programme of activities but there is little evidence of a consistent application of it such as an individual records of participation, the daily routines have been amended to provide more opportunities for activities to take place. Events are said to take place morning and afternoons on all days and include crafts, games, exercises and music. A visiting crafts leader brings variety but this is only on a two weeks basis or guidance sought for staff to lead during the intervening time. Visitors have said they have not seen much activities for stimulation and interest. Visiting arrangements remain unchanged and service users continue to receive visitors at any reasonable time in the day and a number were observed to Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 14 arrive and leave during the course of the day. Most service users receive their visitors in one of the lounges and there appears to be a good relationship between visitors and other service users. One visitor spoken with said the home is improving with the new manager and deputy in post. Opportunity was taken to observe the lunchtime meal at which service users were given a meal of gammon and parsley sauce, potato croquettes and mixed veg, the alternative being fish cakes, both choices were seen to be taken up. Dessert was apple pie with custard or ice-cream, the meal served appeared appetising and well received. It was observed that those requiring assistance were receiving it but a carer was observed assisting two service users at the same time, to presumably prevent the meals going cold. This is not a good practice. Service users may benefit from the provision of plate guards and dycem mats to enable them to eat their meals independently. A dietician is currently actively supporting the home to address individual service users nutrition problems. Other aspects of the menu includes breakfast of porridge cereals and toast with a full cooked breakfast twice a week, tea includes a choice of sandwiches and a light hot course and supper is included on the menu. During the inspection a carer asked the service users for their choice for tea, it was observed that she had omitted to include the hot choice due to it being very small print added at a later time, the inspector also at first thought there was no choice other than two sandwich fillings. The cook demonstrated that he had made the ingredients available for the hot choice. The carer did re offer the tea choices and a number took up the hot option. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are not confident that their concern, complaints will be listened to and acted upon. Service users cannot be assured that they will be protected at all times EVIDENCE: The home is now keeping a log of some of the complaints it receives but the information is minimal and does not show the detail of the investigation or the outcome. The complaints procedure is available and generally meets the National Minimum Standards but the manager must be able to provide this information in formats that meet service users requirements, such as pictorial, large print or audio versions. Service users have commented that they feel their complaints are not acted upon, when asked if they knew who to talk to if they were not happy, one service user answered “yes but to no avail it seems to fall on deaf ears”. Service users are not confident that they have all the information they need to make a complaint and some could not remember receiving a copy of the complaints procedure. Since the last inspection some of the staff have received training the Adult Abuse Awareness but this training must continue until all staff have completed it. The home’s policy for the Protection of Vulnerable Adults needs to be Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 16 reviewed promptly to ensure that staff are working alongside the Local authority guidance at all times. The homes recruitment policy and practice does not safeguard service users, new workers are permitted to begin working in the home without the necessary Protection of Vulnerable Adults first and Criminal Record Bureau disclosures in place. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of décor, furnishings and managed services providing a safe environment, a comfortable, attractive, and homely place in which to live. The internal locks are unduly restrictive. The home is clean and hygienic and free from odours. EVIDENCE: On arrival at the home there was no malodour on entering the building. A tour of the building, found that while the cleaning schedule was still in progress the home was clean and odour free except room 17 which had a commode that had not been removed. A check of other commodes around the building found them all clean. The EMI lounge has been refurbished, reorganised and provides an improved environment. The adjacent toilet floor covering is in Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 18 poor condition and requires replacement. A wheelchair/ hoist storage area had a new hoist and a large number of wheelchairs. All of the wheelchairs had foot rests, many of the frames look dirty and the manager had no information of when they were last serviced, none had lap straps. The EMI communal area has locks fitted to both doors with codes to exit and switch to enter, this was observed to create frustration for one service user creating an aggressive outburst, which was easily resolved when allowed to leave the area accompanied by a carer. The positioning of these locks need to be reviewed as they appear to be unduly restrictive. The residential communal area has also been refurbished and furnishings are in good condition. There are adjacent toilets it was found that the first was unserviceable with a disconnected flush handle which was addressed immediately and neither had a bin to receive disposed paper towels. The use of low energy bulbs in wc’s is inappropriate as many have no natural light and take a long time to reach a level of lighting that allows safe use of the facility. A check of bedrooms show that they all have a call system, overhead and over bed lighting, covered radiators, restricted windows and appropriate furniture. Not all have a lockable facility although signs of ongoing fitting was seen as is the programme for fitting door locks which is well progressed. Most bedrooms had some proportion of personalisation with pictures, ornaments and other items such as soft toys and memorabilia. Some fitting of secure pictures should be considered for those rooms with no other personal items. The laundry is fitted with washers that have sluicing and disinfection programmes and while small, is well organised. The sluice room on the first floor has a sluice disinfector, the room itself was clean and tidy, the extractor fan has no override to continue running after the light is switched off. The staff room is uninviting but adequate, the lockers are in poor condition and not suitable for use as locks are damaged or missing or missing keys and require replacement or repair. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff are not recruited safely and therefore service users cannot be assured that they will be cared for by competent and experienced staff. EVIDENCE: Staff files were viewed in order to assess the progress the home has made in improving their recruitment practices. Serious concerns were expressed during a random inspection about the lack of information held on staff files, it was very disappointing to see that little improvement has been made. The Commission will be seeking further legal advice. Staff files continue to lack the required information and more worryingly staff are being recruited without the appropriate safety checks being in place. One new worker commenced employment before the home had obtained a PoVAfirst check. Once new workers have started employment there are ineffective systems in place to supervise them and provide an induction programme. Of the files seen none had any record that an induction had taken place. Staff were spoken to who agreed that they had not had an induction but felt that they knew the job anyway because of their previous experience. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 20 Records of training are insufficient and the inspector was unable to determine how many of the staff have completed their NVQ level 2 training or whether staff are enrolled on the course. This means that potentially the staff do not possess the knowledge and skills to care for service users. Staffing levels appear to be stable but the manager should give consideration to supplying more staff at busy times of the day when service users require more attention, for example meal times and periods of activity. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not run in the best interests of the service users, however the environment is well maintained and the health and safety of service users is generally promoted. EVIDENCE: Since the last inspection the registered manager has left and a new manager has commenced employment. The registered providers must apply for registration for the manager promptly. There has been improvement on the quality assurance systems, the home does not seek the views of its service users, relatives or staff when considering the quality of the service they provide. This must be improved and the Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 22 manager must take into consideration the needs and capabilities of the service users when planning how to involve them in this process. The maintenance contracts for the building were spot checked and found to be in order. There are gaps in fire safety training and fire drills for all staff that must be addressed promptly, all other mandatory training has been organised for staff to attend. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 1 1 1 1 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 1 X X 2 Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 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 OP1 Regulation 4 (1)(c),6 Requirement The registered provider must review the Statement of Purpose to ensure that all required information is included and kept up to date. The registered provider must review the content of the service user guide to ensure that all the required information is included. The registered provider must remove the list of service users names from the service user guide The registered provider must ensure that all service users are provided with a contract and a terms and conditions of residency in a timely way. These must be reviewed using guidance from the Office of Fair Trading publication 2003 (previous timescale of 28/09/06 not met) Timescale for action 31/01/07 2. OP1 5, 6 31/01/07 3. OP2 5(1)(b)(c) 31/01/07 Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 25 4. OP3 14 The registered person must ensure that all service users have a needs assessment and there is a copy of it in the service user plan. The registered person must be able to demonstrate the involvement of service users within this process The registered person must confirm in writing to the service user that the home can meet their needs prior to admission. (Previous timescale not met 28/09/06) The registered manager must ensure that systems are in place to deal with emergency admissions and the provision of a needs assessment. Emergency admissions procedure must be included into the homes admission policy. 31/01/07 5. OP3 14 (2) (a) (b) The manager must ensure that 31/01/07 all health needs are documented within the needs assessment and that they are reviewed at least monthly. (Previous timescale 28/09/06 not met) The registered person must ensure that individual bed rail risk assessments are completed and kept under review. This was an immediate requirement at random inspection 13/09/06 The manager must ensure that systems are put into place to demonstrate service user involvement in the planning of their care. DS0000066864.V319627.R01.S.doc 6. OP7 13(6) 31/01/07 7. OP7 15(1) 31/01/07 Summerfield Version 5.2 Page 26 Care plans must be more person centred in their planning. (previous timescale of 28/09/06 not met) 8. OP8 13 (5)sch 3, 3(m o) The manager must ensure that all service users are screened for malnutrition on admission and regularly after that. There must be clear guidance for all staff and management plans formulated for dealing with service users weight loss All risk assessments must be reviewed regularly and reflect the changing needs of service users. The manager must seek advice on the provision of pressure relieving equipment for at risk service users to use when seated out of bed. All service users moving and handling needs must be reassessed and appropriate and safe systems for lifting introduced. (previous timescale of 28/09/06 part met) 9. OP9 13(2) A record must be kept of the temperature of the medication room and the medication refrigerator and documented action taken if found to be outside recommended safe levels. (This requirement is outstanding from a previous inspection and has not been met. Part met) 31/01/07 31/01/07 Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 27 The date of opening of all medicine containers should be recorded and any balances of medicines carried over onto a new medicine chart in order to undertake a medicine audit. Accurate and up to date written records of the current medicine regimes are made and the Medication Administration Record (MAR) chart records exactly what has been prescribed and administered. Staff drug audits must be undertaken before and after medicine rounds to ensure all staff administer medicines and accurately record the administration of medicines in accordance with the doctors instructions. To review and update the medication policies and procedures to ensure they reflect good practice and to train staff to adhere to them. (Previous timescale of 20/10/06 not met) The registered person must consult with service users about the programme of activities provided ensure it includes some dementia appropriate events and maintain records of activity and participation. The registered person must ensure that choice is offered of meals served. Individual assistance with feeding must be individually undertaken in order to maintain good hygiene practice. 10. OP12 16 (2)(n) 31/01/07 11. OP15 16(2) 31/01/07 Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 28 12. OP16 22 The registered person must develop a complaints procedure that is appropriate to the needs of the service users. The registered person must ensure that all complaints are fully investigated with records kept that include outcomes. All service users must be issued with a copy of the complaints procedure in a format that is suitable for them. The registered person must ensure that all staff receive adult abuse training this must include night staff. The vulnerable adults policy must be updated to reflect current good practice. A copy of the new policy must be distributed to staff and written records kept of their receipt of it. All staff must receive training in “behaviour that challenges” The garden is made safe and is accessible for residents. Partially met. This should have been addressed by the 31/7/05 The fitting of bedroom door locks is to be completed. The registered person must ensure that wheelchairs are kept clean and serviced. Floor coverings in toilets are to be replaced as they become stained or damaged. The process of fitting a lockable facility in bedrooms and locks to the bedroom doors must be completed. Toilet and sluice extractor fans should be adjusted to overrun to ensure odours are removed. DS0000066864.V319627.R01.S.doc 01/02/07 13. OP18 13(6) 31/01/07 14. OP19 23(2)(o) 31/01/07 15. OP19 23(2)(c) (b) 31/01/07 Summerfield Version 5.2 Page 29 Service trolleys in the kitchen must have replacement shelves fitted. 16. OP19 16(2)(k) The registered person must ensure bins are available in toilets to receive general waste of disposed towels at all times. 23(3)(a)(ii The responsible person must provide suitable facilities for staff including storage facilities. Staff lockers must be repaired or replaced. 18,17(2) The registered person must ensure that accurate records are kept of all staff training and they are kept up to date. The registered person must forward to the CSCI an up to date list of all staff training in regard to NV Q training. The registered person must not allow workers to commence employment without required information being obtained, PoVAfirst CRB The registered person must ensure that where CRB has been applied for new workers there are appropriate safeguards in place. Appoint a member of staff to supervise the new worker. Ensure that the member of staff is on duty the same time as the new worker. The registered person must ensue that all of the required information in respect of staff is obtained and kept on their file. 20. OP30 18 (2)(3)(4) The registered person must improve the induction DS0000066864.V319627.R01.S.doc 31/01/07 17. OP19 31/01/07 18. OP28 01/12/06 19. OP29 17(2) 19 sch2 sch4 01/12/06 31/01/07 Version 5.2 Page 30 Summerfield programme for new workers that meets with Skills for Care Standards. The registered person must also ensure that an appropriately qualified and experienced staff member supervises new workers. Every member of staff must be issued with a GSCC code of practice with a written record kept of those staff who have been issued a copy. The registered provider must put forward a manager for registration with the CSCI The registered person and manager must implement fully a programme quality assurance monitoring that includes obtaining service users and their representatives views. 21. 22. OP31 OP33 8(2) 24 31/01/07 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP18 OP26 Good Practice Recommendations In addition to current adult protection training it is recommended that senior staff attend the local social services training. It is recommended that the manager obtain a copy of the Department of Health guidance “infection control in care homes” June 2006. Summerfield DS0000066864.V319627.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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