Inspection on 31/01/06 for The Limes Blackheath

This inspection was carried out on 31st January 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 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Limes Blackheath 17/04/09

The Limes Blackheath 14/10/08

The Limes Blackheath 26/10/06

The Limes Blackheath 24/08/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 The Limes Blackheath 37 Avenue Road Blackheath West Midlands B65 OLP Lead Inspector Jayne Fisher Announced Inspection 31st January 2006 09:00 The Limes Blackheath DS0000063539.V274880.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 The Limes Blackheath DS0000063539.V274880.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. The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Limes Blackheath Address 37 Avenue Road Blackheath West Midlands B65 OLP 01384 423225 0121 561 1333 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mohammed Iftikhar Ali Debbie Bennett-Hopper Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Limes is registered to make provision for a maximum of eight people with learning disability. The home is situated within easy travelling distance of Blackheath town centre and close to public transport systems. The home has its own transport. This is used for holidays, group outings and to take service users to appointment, where applicable. Service user accommodation is provided over two floors. There are eight single bedrooms, four of which have en-suite facilities. The communal facilities on the ground floor consist of a lounge/dining area, conservatory and kitchen. Toilets and bathing facilities are available on both floors. There is a garden to the rear of the building. The main entrance is at the front of the building and limited car parking facilities are available at the side of the property. The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted between the hours of 9.00 a.m. and 5.00 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: case tracking, interviews with the manager, and two support staff who were on duty. There was also a tour of the premises. All residents were at home during the varying stages of the inspection. They were happy to participate and showed the inspector their bedrooms. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of visits undertaken by the owner, an action plan submitted by the home following the last inspection and a pre-inspection questionnaire. One relative completed a feedback questionnaire and six residents completed feedback comment cards prior to the inspection. The home provides care for eight adults who have learning disabilities. All residents are self advocating and require varying levels of support. The majority of standards were examined at the last inspection and this report should therefore be read in conjunction with the previous inspection report to give a comprehensive overview. The findings of this inspection confirmed that the manager and staff are striving to meet the National Minimum Standards and are improving upon the quality of support and care provided. The inspector was made to feel very welcome and would like to thank service users and staff for their assistance and co-operation during the visit. What the service does well: There is a strong emphasis on supporting residents to take control of their own lives and to achieving individually appropriate life styles. Residents are able to make their own choices and are encouraged to do so. Daily routines are operated around residents’ preferences and needs with priority given to independence. For example, residents hold their own bedroom door keys, choose their own meals, manage their own medication, have access to the local community and can travel independently. Bedrooms are decorated and furnished to suit individual tastes. They contain lots of personal possessions and equipment and feel homely. There are no restrictions upon residents movement within the home; they can make their own drinks and snacks when they wish and seem relaxed and comfortable in their surroundings. Staff ensure that residents are given opportunities to maintain and develop social, emotional and independent living skills. The manager is proactive in identifying any health care issues and ensuring residents receive appropriate The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 6 guidance and treatment. Residents know that they can approach the manager if they are unhappy or upset and there is a comprehensive complaints procedure in place. Positive comments were received by all residents and a relative who completed questionnaires regarding the care and support provided by staff. During interviews one resident stated that he liked living at The Limes because, “I like the staff, my freedom, independence and the meals”. There is a strong commitment to staff training and residents are supported by qualified staff who know their likes and dislikes. There was positive interaction observed between staff and residents through out the day. Staff demonstrated that they are aware of residents’ rights to privacy and dignity. All communal areas were seen to be extremely clean and tidy. What has improved since the last inspection? What they could do better: The statement of purpose requires amending to given residents up to date details regarding management and staffing. Care plans are still in the early stages of development because the manager wishes to ensure that the most appropriate format is identified, and that staff and residents participate in developing their own care plans through a person centred planning approach. Risk assessments are good although will need to be developed further once care plans have been implemented. There are good procedures relating to the control and administration of medication although some improvements are needed to ensure safer practice. The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 7 Refurbishment is slow but on-going. Difficulties have arisen through trying to find contractors to carry out works and there is no handyperson to carry out routine maintenance and repair. The manager has been covering shortfalls in staffing as there is currently a deputy manager vacancy. This has inevitably had an impact upon some management tasks such as the frequency of formal and recorded supervision of staff and reviews of policies and procedures. 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 Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not evaluated at this inspection. EVIDENCE: Progress was monitored towards outstanding requirements. The statement of purpose still requires further updating to incorporate changes to staffing and management. Upon completion this document should be forwarded to the Commission for Social Care Inspection. There have been new no admissions to the home which is fully occupied. The Limes Blackheath DS0000063539.V274880.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): 6 and 9 Care plans and risk assessments require expansion as they do not cover all aspects of personal and social, and health care; this could have the potential to place service users at risk. EVIDENCE: Progress has been slow towards implementing a comprehensive care planning system. The manager states that it is her intention to introduce a key worker system in order that staff can be fully involved in developing care plans and assist service users to participate in person centred planning. This is a sensible approach which demonstrates forward thinking and ensures that care plans will be useful tools for staff and at the same time have meaning for residents. At present there are detailed needs assessments with regard to personal support and independent living skills. There are personal profiles for each service user which give useful information to the reader, such as how residents communicate. There are detailed care plans in place regarding behavioural management, slight amendments are necessary for one resident due to changing needs although this cannot be progressed until psychologist input has been received. The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 11 In general there are detailed risk assessments in place although some of these will need to be developed further once care plans are in place. A risk assessment is in place with regard to a wheelchair user however this requires expansion to include all the risks associated with this equipment and as highlighted by the Medicines and Healthcare Products Regulatory Agency. Any other items discussed during evaluation of these standards are contained within the Requirements section of this report. The Limes Blackheath DS0000063539.V274880.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): These standards were not assessed at this inspection. EVIDENCE: These standards were fully evaluated at the last visit. Progress was monitored towards outstanding requirements. It is pleasing to see that new transport has been purchased since the last visit as problems with the last vehicle had been instrumental in restricting outings into the community. Residents talked about their recent outings to a museum and spoke of how they had enjoyed a trampoling activity. During interviews residents no longer complained about not being able to go out into the community as much as they had previously. They expressed satisfaction with the level of community based activities. There are separate sheets for recording residents’ outings and activities. Examination of these documents and daily reports demonstrate that there are frequent outings into the community. For example, during one month one resident had gone to Halesowen, enjoyed bowling, trampoling and a visit to the museum as well out going on various shopping trips. During interviews staff stated that they felt that as there was now less emphasis on household chores residents were free to follow their own hobbies and leisure pursuits. Residents The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 13 are still encouraged to travel independently and this is fully risk assessed and managed. Reviews of individual activity programmes are on-going. These are not yet fully completed as staff are still in the process of trying to identify appropriate resources, which according to the manager are somewhat limited. However, it is encouraging to see progress which is being made due to the continuing efforts of staff and management. For example on the day of the inspection one resident was going to undertake a new computer course. All six residents who completed comment cards felt that there were suitable activities provided. There are records of residents’ daily choices from the menu. Alternative options chosen by individual residents are fully recorded by staff. The current system is appropriate and the manager is fully aware that if any residents develop nutritional or eating problems, that more individual monitoring and recording may be necessary. The Limes Blackheath DS0000063539.V274880.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): 18 and 20 Personal support is offered in such as way as to promote residents’ privacy, dignity and independence. The systems for the control and administration of medication are fairly good but some areas need slight improvement in order to fully ensure safe practice. EVIDENCE: There was ample evidence to demonstrate that staff respect residents’ rights to receive support in a way they prefer. As already stated there are detailed assessments of how residents require support with personal care and hygiene. It was pleasing to see that staff understand the rights to privacy and in particular would not discuss an individual resident’s needs over the telephone while another resident was present in the room. One resident who was interviewed confirmed that staff always knocked his bedroom door before entering. All six residents who completed comment cards felt that staff respected their privacy, treated them well and felt well cared for. A relative who completed a questionnaire stated that they could see their family member in private if they wished and were kept informed of important matters. Case tracking and interviews with management confirmed that the health care needs of residents continue to be well met. There are detailed summary report sheets containing information regarding health care appointments, outcomes and treatment. All residents are now receiving monthly recorded weight The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 15 checks. Discussions with the manager confirm a proactive approach to accessing prompt treatment for any potential complications identified. For example, one resident has fluctuating weight and the manager has requested a referral to the community dietician. Whilst there are good records as to how one diabetic service user receives support, a holistic care plan still needs to be developing utilizing all the information contained within these record sheets and also identifying how staff monitor the resident who is self medicating and who monitors their own blood glucose. It is encouraging to see how staff support residents to self medicate. There are detailed risk assessments in place, although corresponding care plans have yet to be developed. On the whole there are good procedures in place with regard to the control and administration of medication although there are some areas which need slight improvement. For example, there are medication profiles contained within service user plans but staff need to ensure that any recent changes to medication are detailed within these profiles. Staff are currently undertaking accredited training in the safe handling of medication. There is no over stocking of medication and the drugs cupboard was clean and tidy with internal and external medication stored separately. All drugs received are checked and recorded upon receipt, however staff need to ensure that they alter any computerized records which may be inaccurate with regard to the number of tablets dispensed. Whilst it was encouraging to see that staff actively monitor residents’ capability with regard to self administration in order to ensure safe practice, care plans and risk assessments had not been updated to reflect changes in one resident’s abilities involving closer monitoring. This had resulted in some confusion when completing the medication administration record (MAR) sheets. Staff are administering Senna for one resident which does not wholly correspond with dosage instructions on the MAR sheet. The manager stated that changes had been made by the doctor and resultant changes had been implemented by a previous manager. However there were no records available within the resident’s care plan to confirm these changes and clarification must be confirmed with the doctor (and MAR sheets altered accordingly). The drugs cupboard is very small and it is recommended that a larger cupboard be purchased including a Controlled Drugs cupboard, as from time to time residents are prescribed such medication. As required, staff have been monitoring the temperature of the drugs cupboard as this is currently located in the kitchen. As a result, on occasions temperatures do exceed 25 C which is the safe limit at which medication can be stored. The storage of medication therefore needs to be reviewed and relocated. Any other items discussed during this inspection are contained within the Requirements section of this report. The Limes Blackheath DS0000063539.V274880.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): 22 There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon EVIDENCE: All six residents who completed pre-inspection comment cards stated that they knew who to speak to if they were unhappy. During an interview one resident confirmed this by saying they would speak to the manager if they were not happy. A relative who completed a feedback questionnaire also stated that they were aware of the home’s complaint procedure. There is a complaint log in order to record any complaints and the outcome of any investigations as is good practice. There have been no complaints received regarding the service during the last twelve months. There are some outstanding requirements with regard to vulnerable adult abuse procedures. Examination of documentation and interviews with management confirm that progress is on-going. For example, staff have been booked on a forthcoming vulnerable adult abuse training course. Procedures have been updated but further information is required for instance with regard to the Protection of Vulnerable Adult (POVA) scheme. The Limes Blackheath DS0000063539.V274880.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): 24 Residents live in a safe and homely environment although some improvements are needed to make the premises more aesthetically pleasant. EVIDENCE: Refurbishment is on-going and some progress (if slow) is being made. Since the last inspection an Immediate Requirement to replace all worn mattresses has been complied with. Staff report that there are plans to refurbish the kitchen in the near future. All wardrobes have now been secured to bedroom walls, although one safety chain had been dislodged in one bedroom. Some communal and individual bedroom carpets could do with replacing as they are becoming worn (although not unsafe). It was pleasing to see that some residents have had new desks/tables although some furniture still requires repair. As identified at the previous visit, although there is evidence of refurbishment with bedrooms currently in the process of redecoration, those that have been completed require finishing touches to bring them up to an acceptable standard. For example, plasterwork on walls is still cracked, there are areas where plaster is worn but has not been filled-in before repainting resulting in uneven walls, the window frame needs sanding and wood treated before painting. The manager states that progress has been hampered due to The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 18 finding contractors who are will to undertake such work and the lack of a handyman who could be permanently employed to carry out repairs etc. It was pleasing to see that new dining room furniture has been purchased since the last inspection which is more suitable for residents’ needs and comfort. Any other items discussed during this inspection are contained within the Requirements section of this report. The Limes Blackheath DS0000063539.V274880.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): 36 Staff receive support and guidance from the manager in order for them to effectively support residents; frequency of recorded supervision sessions would further enhance this practice. EVIDENCE: Progress was monitored towards outstanding requirements at this visit. It was reassuring from discussions with the manager that specialist training is still a priority although problems have been incurred with regard to finding suitable trainers. A previous requirement with regard to reviewing staffing levels and producing an assessment of residents’ dependency profiles has been withdrawn as the manager has demonstrated that reviews of staffing ratios to meet residents’ needs is an on-going process. No new staff have been employed since the last inspection. The manager is hoping to recruit to a couple of vacancies in the near future. The manager and staff team have been covering any shortfalls in staffing levels; agency staff are also used as and when necessary. There is a small staff team and a couple of staff are under twenty one years of age. However, it is encouraging to see that despite the difficulties this poses, these staff are not left in sole charge of the premises as in compliance with the National Minimum Standards. The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 20 During interviews staff indicated that they felt supported by the manager and were included in decision making. There are comprehensive supervision records. On examination these demonstrate a proactive management approach to raising care standards or tackling any issues with practice. The manager states that as there is a small staff team supervision is an on-going process. However, the frequency of recorded formal supervision sessions require improvement in respect of some staff. For example, one member of staff had not received a recorded supervision session since December 2003. The Limes Blackheath DS0000063539.V274880.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): 37 The manager provides clear leadership through out the home with staff demonstrating an awareness of their roles and responsibilities thereby protecting service users’ rights and interests. EVIDENCE: The manager has now been in post for nearly twelve months. Staff report positive effects from the change in management. For example, “since the new manager residents have come on a lot better, it is completely different, they are listened to now”. Staff felt daily routines are less regimented and as a result residents are given more opportunities for personal development. One resident stated, “I like Debbie” (the manager), when being asked about staff. Records from staff supervision and meetings demonstrate good communication between the manager and staff with appropriate topics discussed during these forums. Unfortunately the manager has been unable to be fully supernumerary because of the lack of a deputy manager and acknowledges that as a result, progress is some areas has been slow as identified during this The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 22 visit. The manager is currently undertaking a Registered Manager’s award and is hoping to start an NVQ IV in care once this has been completed. A job description needs to be devised which sets out all management responsibilities. On examination of the central staff development programme and training certificates there is evidence of on-going statutory training. The majority of staff have now completed health and safety training and are due to commence an accredited training course in infection control. All staff have recently completed an accredited fire safety training course. Since the last visit an inspection has been conducted by the West Midlands Fire Safety Service. Two requirements were made which have subsequently received action. There is now improved testing of the fire alarm system and emergency lighting. Improvement have also taken place with regard to food hygiene practice. A couple of outstanding items remain with regard to freezers which require repair or replacement. A new fridge has recently been purchased. As required the owner is visiting and completing a monthly report which is forwarded to the Commission for Social Care Inspection. Any additional items discussed during this inspection are contained within the Requirements section of this report. The Limes Blackheath DS0000063539.V274880.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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X 2 X X X X 2 X The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement Timescale for action 01/05/06 2. YA6 15 To amend Statement of Purpose and Service User Guide to ensure it accurately reflects service provision and complies with current Standards and Regulations (to forward to the Commission for Social Care Inspection). (Previous timescale of 1/1/04 is not met). A written plan, which details how 01/05/06 all their care needs are to be met by the home, must be produced for each service user. To include all aspects of care and with clearly stated goals and objectives with timescales for monitoring. (Previous timescale of 1/1/04 is partly met). To carry out a review of all service users individual behavioural management programmes. To ensure that there are explicit guidelines for staff to follow based on professional best practice. (Previous timescale of 1/6/05 is partly met). To introduce a person centred The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 25 3. YA7 17(2) 4. YA9 13(4)(c) 5. YA10 12(4)(a) planning process to assist service users with developing their care plans. (Previous timescale of 1/12/05 is partly met). Where any restrictions are made on a service users right to make their own decisions, this must be discussed with all relevant people, agreed, recorded and regularly reviewed. For example with regard to financial decision making, opening of residents mail and cross gender personal care. (Previous timescale of 1/1/04 is partly met). Individual risk-taking assessments must be undertaken on all service users and regularly reviewed, i.e. with regard to challenging behaviour, wheelchair users etc. (Previous timescale of 1/1/04 is partly met). To establish a detailed policy regarding Confidentiality including a statement on confidentiality to partner agencies. (Previous timescale of 1/1/04 is partly met). 01/05/06 01/05/06 01/05/06 6. YA12 16(2)(n) To produce written procedures regarding service users access to their own records. To distribute these to service users with documented evidence kept that this has been carried out. (Previous timescale of 1/1/04 is partly met). To undertake a review of 01/05/06 individual activity programmes in consultation with service users with a view to increasing the number of leisure and social activities (in-house and community based). (Previous timescale of 1/6/05 is partly met). DS0000063539.V274880.R01.S.doc Version 5.1 Page 26 The Limes Blackheath 7. YA19 12(1)(a) To introduce a procedure for the monitoring of service users health with regard to potential complications such as breast screening, testicular screening etc. (Previous timescale of 1/1/04 is partly met). To establish a care plan for a service user who is diabetic to include all aspects of diabetic care including: skin, eyes, foot and dietary care, potential complications and monitoring by specialists. (Previous timescale of 1/10/04 is not met). 01/05/06 8. YA20 13(2) To improve the control and administration of medication: 1) Medication policy/procedures must be reviewed and include details of all aspects of the safe handling of medication. (Previous timescale of 1/11/03 is partly met). 2) To arrange for all staff to undertake accredited training in the safe handling of medication. (Previous timescale of 1/11/03 is partly met). 3) To ensure that all medication received into the home is fully recorded. (Previous timescale of 1/11/05 is partly met). 4) To ensure that two staff initials are obtained to confirm any changes made to computerized instructions on Medication Administration Record (MAR) sheets. (Previous timescale of 1/11/05 is not met). 5) To ensure that medication 01/05/06 The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 27 administration record (MAR) sheets are accurately completed with no gaps. (Previous timescale of 1/11/05 is not met). 6) To ensure that medication profiles are kept up to date for all service users. 7) To relocate drugs cupboard (currently stored in the kitchen area), to ensure storage temperature does not exceed 25 C. 8) To clarify dosage of Senna for ‘A’ with the prescriber and alter medication administration record (MAR) sheet and medication profile accordingly. 9) To ensure that care plans and risk assessments are updated as and when there are any changes to service users’ capacity to self administer their medication. 10) To ensure that care plans contain guidelines with regard to the administration of ‘as and when’ required (PRN) medication including pain relief. 11) To ensure that any ‘as directed’ instructions are clarified on MAR sheets. 12) To ensure that creams/ointments are labelled with the date of opening. The home must review its Adult Protection policy/procedure to ensure compliance with the Department of Health Guidance and associated legislation (this must include procedures regarding the new Protection of Vulnerable Adults (POVA) DS0000063539.V274880.R01.S.doc 9. YA23 13(6) 01/05/06 The Limes Blackheath Version 5.1 Page 28 scheme. (Previous timescale of 1/1/04 is partly met). To provide all staff with training in vulnerable adult abuse. (Previous timescale of 1/4/04 is not met). To review and expand the Whistle Blowing policy to include contact names and numbers for senior management and to cover false allegations and misuse of the policy. (Previous timescale of 1/11/05 is not met). To undertake the following improvements to the environment: To carry out an audit of the premises and establish a written programme of maintenance and refurbishment. To forward a copy to the CSCI together with timescales for completion of works identified. (Previous timescale of 1/5/05 is partly met). 1) To clean or replace stained and/or worn carpets in communal areas and individual bedrooms. (Previous timescale of 1/12/05 is partly met). 2) To repair cracked plasterwork in individual service users bedrooms. (Previous timescale of 1/12/05 is not met). 3) To progress plans to replace worn flooring in the first floor shower room. (Previous timescale of 1/12/05 is not met). 4) To replace worn mirror in first floor shower room. (Previous timescale of 1/12/05 is The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 29 10. YA24 23(2)(b) 01/05/06 not met). 5) To investigate and repair creaking floorboards in service users bedroom. (Previous timescale of 1/12/05 is not met). 6) To repair worn flooring in service users ensuite toilet. (Previous timescale of 1/12/05 is not met). 7) To repair worn window frame in service users bedroom. (Previous timescale of 1/12/05 is not met). 8) To ensure all wardrobes are securely fixed to bedroom walls. (Previous timescale of 1/12/05 is partly met). 9) To replace all worn bedroom furniture. (Previous timescale of 1/12/05 is partly met). 10) To carry out a written risk assessment with regard to the use of multiple electrical adaptors. (Previous timescale of 1/12/05 is not met). 11) To replace worn kitchen units. (Previous timescale of 1/12/05 is not met). 12) To replace stained grouting around showers and bath. 11. YA30 13(3) To ensure COSHH information is held and displayed in the laundry. (Previous timescale of 1/6/04 is not met). Job descriptions must be reviewed and linked to the DS0000063539.V274880.R01.S.doc 01/05/06 12. YA31 18(1)(a) 01/05/06 The Limes Blackheath Version 5.1 Page 30 homes Statement of Purpose and the individual needs of the service users. - (Previous timescale of 1/12/05 is not met). All staff must be provided with a copy of the General Social Care Council standards of conduct and practice. (Previous timescale of 1/12/05 is partly met). To provide specialist training for all staff in: 1) Autism awareness. (Previous timescale of 1/4/04 is not met). 2) Diabetes awareness. (Previous timescale of 1/4/04 is not met). 3) Epilepsy awareness. (Previous timescale of 1/4/04 is not met). 4) Understanding challenging behaviour. (Previous timescale of 1/6/05 is partly met). To ensure that all staff meetings which take place are fully recorded (minimum six per year). Staff must be provided with a structured induction and foundation training programme that is provided by a Learning Disability Awards Framework registered provider. (Previous timescale of 1/1/04 is not met). To provide staff with training in equal opportunities and disability equality. (Previous timescale of 1/4/04 is not met). To establish individual training and development assessment profiles for all members of staff. (Previous timescale of 1/1/04 is The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 31 13. YA32 18(1)(c) 01/05/06 14. YA33 18(1)(a) 01/05/06 15. YA35 18(1)(c) 01/05/06 not met). 16. YA36 18(2)(a) To ensure that all staff receive a minimum of six recorded supervision meetings per year. 01/06/06 17. YA37 18(1)(c) To introduce an annual appraisal system for staff. To ensure that the manager is 01/06/06 qualified to NVQ IV in care and management by 2005. (Previous timescale of 31/12/05 is not met). To ensure there is a manager’s job description which describes all responsibilities under the Care Standards Act and relevant legislation and codes of practice. Effective quality assurance 01/06/06 systems must be developed by the home. (Previous timescale of 1/12/05 is not met). Policies and procedures must be 01/06/06 reviewed regularly using current professional guidelines and legislation. (See Appendix 3 of the National Minimum Standards for Younger Adults). (Previous timescale of 1/8/04 is partly met). To provide training for all staff 01/05/06 commensurate with their duties which include: 1) Moving and handling. (Previous timescale of 1/1/04 is partly met). 2) Infection control. (Previous timescale of 1/1/04 is not met). 18. YA39 24 19. YA40 24 20. YA42 18(1)(c) 21. YA42 13(4)(c) To improve health and safety practice: To carry out written risk assessment for all Control of 01/05/06 The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 32 Substances Hazardous to Health (COSHH) products which are used. (Previous timescale of 1/11/04 is partly met). To undertake chlorination and bacterial analysis of the water system. (Previous timescale of 1/11/05 is not met). To make the following improvements to food hygiene practice: 1) To replace or repair upright freezer which has become rusty in places. (Previous timescale of 1/11/05 is not met). 2) To defrost and repair broken drawers on small freezer located in the kitchen. (Previous timescale of 1/11/05 is partly met). 22. YA42 13(4)(c) 01/05/06 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. Refer to Standard YA18 YA20 Good Practice Recommendations To consider introducing a key worker system. To consider purchasing a larger drugs cupboard including a cupboard for the storage of Controlled Drugs which meets the requirements of the Misuse of Drugs Act 1964. To obtain a Controlled Drugs register in which to record all administration, receipt and disposal. The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 33 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. Extracts may not be used or reproduced without the express permission of CSCI The Limes Blackheath DS0000063539.V274880.R01.S.doc Version 5.1 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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