Inspection on 20/09/06 for The Keepings

This inspection was carried out on 20th September 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 but made no statutory requirements on the home.

Other inspections for this house

The Keepings 14/04/10

The Keepings 23/01/09

The Keepings 16/01/06

The Keepings 29/03/05

The Keepings 02/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Keepings 12 Priory Road Dudley West Midlands DY1 4AD Lead Inspector Mr Jon Potts Key Unannounced Inspection 10:10 20 & 21st September 2006 th 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 The Keepings DS0000024961.V311595.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. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Keepings Address 12 Priory Road Dudley West Midlands DY1 4AD 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 253560 01384 214726 gordannuttall@tiscali.co.uk Mr Gordon Nuttall Vacant Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation report dated 6 September 2004 may be accommodated at the home in the category DE (E). This will remain until such time that the service users placement is terminated. 16/01/06 Date of last inspection Brief Description of the Service: The Keepings is a large converted and extended domestic property located within easy reach by foot of Dudley Town centre, and therefore close to all public amenities. There is car parking to the front of the property and on the main road. There is a large garden to the rear, this well established with a variety of plants and a large patio area adjacent (with a number of tables and chairs available). The home has 19 single and 2 shared rooms. Resident’s accommodation is on two floors, the upper floor accessed by a stair lift. The bedrooms are individually decorated and reflect differing resident’s tastes and personalities. Residents can bring in their own furniture if they wish dependent on space requirements and following discussion with the provider. The home has a number of bathrooms with assisted bathing facilities on each floor. There is a large lounge with patio doors leading to a ramp with handrails. The dining area is situated on the ground floor. Communal areas are decorated and furnished to a high standard. The home has undergone building works in the last 2 years to increase the number of beds available from 17 to 23 as well as improving the available space in communal areas, this now complemented by a new conservatory. The home is run by a manager/joint provider in the absence of a registered manager who has responsibility for, a number of senior staff and then carers. There is also ancillary staff including cooks, domestics, handyman and administrator. In addition the other joint provider is available at the home for the majority of the week. The homes standard fee for accommodation per week is between £337.50 to £343 although there maybe a ‘top up’ charge of between £86.90 to £147.33 a month for such as larger rooms or rooms with ensuite facilities. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, which looked at all the key standards within the NMS, was carried out over two days and involved case tracking the care provided to three residents, this involving examination of all the homes records relating to them, discussion with the residents themselves, staff involved in delivery of their care and where possible relatives. There was also discussion with two directors of the company that carries on the home (during and following the inspection)as well as exploration of a range of documentation including training records, staff files, quality assurance monitoring records, health and safety documentation and other general records related to service provision. Residents, staff and management are to be thanked for their ready assistance with the inspection process and hospitality. What the service does well: What has improved since the last inspection? The service has addressed a number of requirements since the time of the last inspection this including risk assessing any residents that self medicate, ensuring two references are obtained for any new staff employed, one from the last social care employer, completing POVA checks on all new staff and providing staff with additional training (including accredited medication training). The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 6 The patio outside the homes conservatory has now been completed, with ramped access, and redecoration of various parts of the home has continued on an on-going basis. The homes stair lift has also been replaced. 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. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 7 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 The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 The outcome for this group of standards is judged to be adequate. Prospective residents and their representatives usually have the information needed to choose a home, which will meet their needs. They have their needs assessed although the homes ability to met needs based on this assessment at times needs to be more thorough. Contracts, which clearly tell them about the service they will receive, are made available but not always complete. EVIDENCE: Prospective residents are invited to spend time in the home prior to moving in and are given verbal information although there was some doubt as to whether they were consistently given a copy of the homes information booklets (i.e. service users guide) this based on comments from residents and relatives. There was also concern that some residents admitted recently were outside of the homes registered categories and issues were arising as a result of one resident’s needs (in respect of dementia). Despite the home having confirmed that it had the ability to meet this resident’s needs in writing prior to admission there were concerns as to staff having sufficient training and skill in dementia care. There were issues with other residents feeling frightened of residents The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 9 with dementia and staff having concerns that other residents were discriminating against the one resident due to their illness. On a positive note staff were aware of these issues and were pursing through care management channels. There was evidence that the management obtain copies of relevant assessments prior to admission and documentation in respect of the required information was in order, although the registered persons need to ensure that admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. This maybe achieved through the management team considering the application in more depth together with other staff, where all information is shared, views, opinions, and comments are listened to and fully debated, before agreement is give for the admission. Where the assessment has been undertaken through care management arrangements the registered person had obtained a summary of the assessment and a copy of the plan. The home provides a statement of purpose (SOP) that clearly sets out the objectives and philosophy of the service supported by a resident guide that summarises the SOP and provides good clear information about the home. The guide is precise in what the prospective resident can expect and gives a good detailed account of the quality of the accommodation, qualifications and experience of staff, how to make a complaint, recent CSCI inspection findings and contains comments and experiences of residents living at the home. Whilst it was stated that all residents are given a copy of the guide, some relatives and residents spoken to were no sure about this, although some stated they had seen the documents. The documents given are in written (and large print) format. Each resident is provided with a statement of terms and conditions at the point of moving to the home. These set out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the resident, although it was noted that some contain gaps in respect of some information (this where there were gaps for individual information that had not been completed). The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The outcome for this group of standards is judged to be good. The health and personal care, which a resident receives, is based on their individual needs, although the management need to ensure that all arrangements for addressing risk are consistently reviewed on a regular basis. The homes systems for the administration of medication are adequate but show room for improvement, this positively identified by the registered provider pre inspection, with action to address this matter now underway. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The service evidenced that it involved residents in the planning of care that affects their lifestyle and quality of life, this echoed in the homes procedures. Residents have a plan that has been agreed with him or her or their appropriate representative. This is written in plain language (albeit handwritten), is easy to understand and considers all areas of the individual’s life including health, personal and social care needs. The plan also includes risk assessments. Areas have been identified where staff are willing to support residents to take some risks, which may have an impact on their rights. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 11 Staff have skills and ability to support and encourage residents to be involved in the ongoing development of their plan and make the process interesting, and worthwhile using a variety of ways e.g. appointing key workers who build up special relationships with residents and work on a one to one basis. The home ensures that each resident’s plan is reviewed regularly (with exception as detailed below) and involves the resident and where appropriate their family. The plan is updated and the necessary action taken to respond to any changes. All members of staff regard the plan as a working tool; they understand the plan and work to it. Residents receive clear feedback on all decisions and actions that affect the placement and their individual care. Residents have right of access to health and remedial services and the home’s policies, procedures and practice guidance strongly support this. Staff work very hard to make sure that all residents have regular appointments and have access to local health care services, supported by family, care staff or volunteers. Residents’ personal aids are well maintained and the home provides the necessary aids and equipment to support both staff and residents in daily living. Residents have individual health care plans that give a comprehensive overview of their general health and acts as an indicator to changing health needs. It was noted that whilst there are nutritional risk assessments in place, one was noted to have not been reviewed since late 2005 and the information contained therein was inaccurate. Other risk assessments, in respect of nutrition and other areas (i.e. falls) were however up to date indicating this one instance was an exception. Residents have the choice to shower or bath when they wish, and are supported and facilitated to be independent in their personal hygiene. Care staff are trained and accredited to meet the health care needs of the residents and have access to training in health care matters e.g. attend seminars and lectures arranged by local health care organisations or via training bodies. The homes systems for the administration of medication seemed to be working although methods of recording in some cases seemed a little haphazard, and access to information when looking at some audit trails took longer than would have been expected, although was present. The home did have a workable medication policy supported by procedures and practice guidance, staff aware of the former with this supported by a number having completed their accredited medication training. The greatest area of concern was the use of secondary dispensing, which the registered provider stated was to be addressed by the soon to be introduced monitored dosage system. This will be introduced following training from the appropriate pharmacist. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 12 The aims and objectives of the home reinforce the importance of treating residents with respect and dignity and these values should be applicable to all aspects of their life and are fundamental to the philosophy of care. Particular attention is given to ensuring privacy and dignity when delivering personal care. Staff make every effort to enable residents to choose who delivers their care and respect their preferences. Recruitment of staff takes into consideration the need to employ a varied and balanced staff group. Induction training covers privacy and dignity. The Keepings DS0000024961.V311595.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The outcome for this group of standards is judged to be good. Most of the residents are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet the majority of the resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: Residents spoken to confirmed that the routines of the home are planned around the resident’s needs and wishes. The home encourages residents to take control of their life and be actively involved in management of their dayto-day life as far as possible, with residents having the confidence to discuss what makes them happy and comment where improvements can be made. The home takes residents feedback seriously and there was evidence that some residents felt that changes had been made in response to their suggestions, choice of foods been a prime example. Staff listen to residents and make considerable effort to provide a flexible service, which enables them to enjoy a better quality of life. There was some question as to whether there were sufficient staff resources provided to allow time for activities and stimulation for all residents, this more an issue for those few service users that are more dependent. The more able The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 14 residents in the home felt they were able to access sufficient stimulation, with organised trips out to such as Stapley gardens and Western hall, these said to be excellent. The availability of the company’s own mini-bus is used to facilitate these trips. The home operates a key worker system, which enables closer resident staff relationships where likes, dislikes and needs are shared. Key workers should use the information to plan activities, which residents do enjoy. Better documentation of the day-to day activities the residents are involved with would be helpful to the home in demonstrating what they offer, especially for those residents that may have limited communication. The home has developed a system for displaying information and bringing attention to community events and activities. Family and friends feel welcome and know they can visit the home at any time. Staff always make time to talk to visitors and share information with the agreement of the resident. The design of the home provides seating areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective for the home. The home will not assume responsibility for resident’s financial affairs and encourages them to manage this themselves, or identify an appropriate representative to assist them. Staff will support those service users who need help in financial matters in so far as directing them to those that are able to offer appropriate advice, for example social worker where local authority funded. The home is able to offer residents information and telephone numbers for contacting independent people who will act as advocates on the residents’ behalf where the service user prefers the help of an independent person. Service users have the choice to bring a limited amount of small goods with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room. These are documented within individual inventories of property. The home believes that service users should always be aware of any information held and written by the home, and have the right to read any documents they wish and staff promote this, this underlined by the homes procedures, which are shared with residents and relatives. Food and mealtimes are treated as an occasion and something to be looked forward to. Residents told the inspector that a new cook had been employed at the home three weeks prior to the inspection and the improvement in food was marked since this point. The records of foods provided showed a range of nutritional meals that meet the cultural and dietary needs of the service users to be provided. The cook/management based on what residents told the inspector have meet regularly with service users, listen to their choices and suggestions for the menu, and made changes based on this. The cook is The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 15 familiar with the dietary requirements recorded in the service users care plan and provides a diet that meets their individual needs. Care staff are sensitive to the needs of those service users who find it difficult to eat and give assistance with feeding. They are aware of the importance of feeding at the pace of the service user, making them feel comfortable and unhurried. Tables are set attractively with the necessary cutlery and aids to help individuals during their meal. They are encouraged to serve themselves and help themselves to drinks. Birthdays and celebration are made special for individual service users. Residents enjoy the flexibility of meal arrangements and enjoyed being able to eat in their own room if they wished. There is also a smaller eating area separate to the dining room if required. Regular drinks are available and staff will always make a cup of tea at any time when asked. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The outcome for this group of standards is judged to be good Most residents have access to a robust, effective complaints procedure, and staff are aware of what steps to take to protect them from abuse. EVIDENCE: The service has a complaints procedure that is up to date, clearly written, and is easy to understand. It is available in written format and is included in the service users guide, terms and conditions and on display in the reception area of the home to enable anyone associated with the service to complain or make suggestions for improvement. Most of the residents and others associated with the home demonstrated a good understanding of how to make a complaint and they are very clear of what can be expected to happen if a complaint is made, although there were some relatives that seemed to be unaware of it. Unless there are exceptional circumstances the service always responds within the agreed timescale. The policies and procedures regarding protection of residents are of a high quality and are regularly reviewed and updated. The service is clear when incidents need external input and who to refer the incident to and staff spoken to showed a good awareness of what abuse could constitute and what to do if they witnessed the same. Training of staff in the area of protection is regularly arranged by the home. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. The The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 17 outcomes from any referral are managed well and issues being resolved to the satisfaction of all involved. Residents and others associated with the service state that they are very satisfied with the service provision, generally feel safe and well supported by an organisation that has their protection and safety as a priority, although there was an issue at the time in respect of disagreements between residents that was been addressed. Staff were aware of this matter and taking the necessary steps to try and resolve the same. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25, 26 The outcomes for this group of standards was judged to be good The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. There was evidence of ongoing work to maintain the environment. The providers were advised to continue documenting and reviewing their on going plans for refurbishment and renewal. It is a very pleasant, safe place to live with some large bedrooms and a number with en-suite facilities. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. The garden was seen to be a pleasant and interesting area that was a source of pleasure to residents, one of which gave the inspector a guided tour. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 19 Some of the residents bedrooms were seen and where wished these were personalised with the presence of individual’s own possessions. The management do provide keys to bedroom doors in accordance with risk assessments that are carried out, although one that was seen was found to be inaccurate. There is a choice of bathing facilities, both assisted and unassisted, showers and baths and there are a number of toilets strategically placed around the home. There is plenty of hot water and the temperature in the home can be changed, on request, in resident’s own rooms. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy. The only issue of note was that an area of the flooring in the laundry was in need of repair or replacement so as to provide an easily cleansable surface. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The outcome for this group of standards is judged to be adequate Staff in the home are, in the opinion of residents, trained and skilled to provide for and meet their changing needs. There is some concern that the lack of domestic staff has detracted from available care staff time, this impacting on such as the provision of activities to more dependent residents. There are still some shortfalls in recruitment practice that could compromise the safety of residents. EVIDENCE: Residents are generally satisfied that the care they receive meets their needs, although the loss of the homes domestic has meant that the care staff are involved in more domestic work of late, this potentially detracting from time they could spend with residents. It was clear from discussion with residents that the providers play a valuable and active part, although the hours documented on the staff rota were not accurate for the days of the inspection. There is a need to review the residents dependencies against the care staffing hours available, this not inclusive of the time spent on domestic tasks. Most of the residents felt that the staff are trained and able to deliver their care needs. Staffing rotas try to take into account the times of high and low activity. Whilst the service acknowledges the importance of training, and delivers where possible a programme that meets any statutory requirements, the training plan The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 21 that was seen was not up to date as staff spoken to indicated that they had received training that was not documented. Based on the training plan there are still some areas, which need attention, although some of these may have been addressed. The home was seen to have an induction procedure that possibly needs to be reviewed against the new skills for care induction standards, information related to the same found in the homes office. Staff are clear regarding their role and what is expected of them and recognise the importance of teamwork. Residents report that staff working with them know what they are meant to do, and that they are generally able to meet their needs. The service has a recruitment procedure that is adequate and generally meets the regulations and the national minimum standards although at a basic level. Whilst the home was seen to obtain a POVA check prior to the employment of any staff, there was no risk assessment available where they were employed prior to receipt of the full-enhanced disclosure. It was also noted that there were some gaps in the records of the working history for some staff, these not explored, as no documented explanations for the same were available. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 38 The outcome for this group of standards is judged to be good. The day to day management of the home has changed due to the registered manager having left, although the providers are covering this gap as best possible. Pleasingly there has been no direct impact in respect of resident care noted at the time of the inspection, although there was some weakness in the quality monitoring system. EVIDENCE: The manager of the home had recently left prior to this inspection and there was discussion with the providers as to how they intended to address this vacancy, during and after the date of the inspection. It was stated that a senior would cover the gap on a temporary basis with support from the providers, with the one provider intending to relinquish management of another home so as to focus more on the management of the Keepings. The providers at the time of the visit stated that they would be available to assist The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 23 with covering the duties of the manager’s post, until more permanent arrangements were put in place. There are systems that have been developed to monitor practice and compliance with the homes plans, policies and procedures, although this has not lead to the development of an annual development plan for the home based on a systematic cycle of planning - action - review, reflecting aims and outcomes for service users. There was evidence of the home using consultation to gain the views of the users of the service, although those seen were not dated and it was not possible to state how old these were. Verbal opinion from residents is gained via service user meetings, the last focused primarily on food. The development of a policy of equality and discrimination in respect of users of the service is advisable so as to give clear direction to staff as to the actions to take when issues in respect of the same arise. . The home has developed a health and safety policy that generally meets health and safety requirements and legislation. There was a need to review and expand the homes risk assessments in respect of safe working practices, this to ensure they are comprehensive and cover the full range of potential hazards within the home. Staff spoken to had a good understanding of their responsibilities in respect of safe working. Residents have the opportunity to manage their own money if they wish, and some facilities are provided to help keep it safe. Where the home manages money on residents’ behalf a system is in place to record transactions and accounts for spending. The arrangements for acting as an agent or appointee to residents meet the basic requirements. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 24 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 2 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 4 3 X X 2 3 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 25 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 OP4 Regulation Care Standards Act Requirement To apply for a variation to the homes certificate of registration due to the number of residents accommodated at the home with dementia, this to demonstrate how the home will meet the needs of this group of residents. To review the nutritional assessment for resident I.D and ensure this is kept up to date. To continue with plans to introduce a monitored dosage system to the home for the safe management of medication. To review the arrangements for activity provision for the homes more dependent residents To ensure all residents and their relatives are aware of the homes complaints procedure. To repair, replace the laundry flooring so as to provide an easy to clean and safe covering. To employ a domestic to free up care staff time for direct care Where staff are employed following all recruitment checks with the exception of an enhanced disclosure (this where DS0000024961.V311595.R01.S.doc Timescale for action 28/02/07 2. 3. OP8 OP9 14 13(2) 31/01/07 31/01/07 4. 5. 6. 7. 8. OP12 16(m) OP16 OP26 OP27 OP29 22(5) 23 18(1) 19 31/01/07 31/01/07 31/01/07 31/01/07 31/01/07 The Keepings Version 5.2 Page 26 there are concerns in respect of compromised staffing levels due to staff vacancies) the provider must carry out a risk assessment that is discussed with the CSCI. Staff employed without a disclosure must work with an existing named and experienced staff member, this until their disclosure is received. The provider must also ensure that there is a record of staff full working history in their file. This is a repeated requirement that was to have been met by the 15/2/06 9. OP30 18(1) c To ensure that the homes training record is kept up to date and reflects the current training provision the home is offering. To recruit a substantive manager for the home and submit an application for registration to the CSCI’s central registration team. There must be an annual development plan for the home based on a systematic cycle of planning - action - review, reflecting aims and outcomes for service users. This is a repeated requirement That was to have been addressed by the 30.4.06. To review the homes health and safety risk assessments 31/01/07 10. OP31 8(1) a 28/02/07 11. OP33 24 28/02/07 12. OP38 13(4) 28/02/07 The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 27 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. 4. 5. Refer to Standard OP1 OP2 OP12 OP24 OP33 Good Practice Recommendations To ensure all prospective and existing residents are issued with a copy of the homes service users guide. To ensure all the gaps in signed contracts are completed so that all necessary information is available. The staff should better document the individual activities residents are involved with on a day to day basis To review the risk assessment in respect of I.D. holding a key their room, this as it was found to be inaccurate. To ensure that quality assurance comment forms are dated. The Keepings DS0000024961.V311595.R01.S.doc Version 5.2 Page 28 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: 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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