Inspection on 22/11/06 for Tiled House

This inspection was carried out on 22nd November 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

Tiled House 11/11/08

Tiled House 14/12/05

Tiled House 18/07/05

Tiled House 20/10/04

Tiled House 27/05/04

Tiled House 30/03/04

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 Tiled House 200 Tiled House Lane Pensnett West Midlands DY5 4LT Lead Inspector Mrs Cathy Moore Unannounced Inspection 22nd November 2006 07:00 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 Tiled House DS0000036816.V320637.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. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tiled House Address 200 Tiled House Lane Pensnett West Midlands DY5 4LT 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 813425 01384 813427 N/K Dudley Metropolitan Borough Council Anita Williams Care Home 48 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (36) of places Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 10 December 2002 are met within the timescales contained within the action plan agreed between Dudley Metropolitan Borough Council and the National Care Standards Commission. Day care provision must not encroach on the facilities, staffing and services provided to residential service users. By the 31 September 2003 water available from bedroom/bathroom taps together with any exposed pipe works shall not exceed 43 degrees Celsius. In the interim following risk assessments, strategies are Implemented to safeguard service users. One service user named in the variation application of 21 April 2004 may be accommodated in the category of PD as a respite placement. This will remain until such time that the identified service users placement is terminated. 14/12/05 2. 3. 4. Date of last inspection Brief Description of the Service: Tiled House is a large forty-eight bedded unit owned and managed by Dudley MBC. The home is located near to Pensnett where there are a number of shops, public houses, a post office and main bus routes to surrounding areas. The home is divided into six residential units, these are situated on two stories. One unit is specifically identified to care for people who are in need of respite or an emergency admission. All bedrooms at the present time are single occupancy. The home does not offer en-suite facilities. Each of the six units are self sufficient other than the centralised services of catering and laundry facilities, which also serve the day unit. Each unit has a separate lounge/dining area with kitchen facilities. The intention of the small units is to ensure a more personalised care service to the residents. The fee range for Tiled House is between £355 and £500 per week. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on one day by one inspector between 07.15 and 18.45 hours. Preparation for the inspection included the analysis of 19 questionnaires completed by residents and information gained by the Commission since the last inspection. Part of the inspection was carried out in lounge areas where observations could be made of daily routines and staff/ resident interactions. Four residents were concentrated on in more detail during the inspection this included looking at their needs assessment , care plan, daily notes and medication records. Where possible these residents and their relatives were spoken to and their bedrooms viewed. Three staff files were assessed as well as agency staff records to see how good the homes recruitment and training processes are. Complaints, quality assurance and medication processes were all examined. The premises were assessed to include three lounges and dining areas, three bedrooms, the laundry, bathrooms, toilets and the gardens. Four staff, five residents and four residents were spoken to. What the service does well: The home is owned and managed by Dudley MBC giving it information and support networks. The home’s atmosphere was warm, welcoming, positive and friendly. Staff observed, were caring and kind. The manager and seniors are very committed and motivated to providing a good service to the people in their care. The manager demonstrates good leadership skills, is proactive and responsive. Over 70 of the care staff team have achieved NVQ level 2 or above. Food served was attractive and plentiful. There are no concerns regarding health and safety in the home. The home provides an open visiting policy. Residents are very much encouraged to maintain contact with family and friends. The giving and receiving of thorough shift handovers observed good communication between staff. The home tries to provide a varied range of activities on a regular basis. Two hairdressers visit the home once a week each giving service users’ the opportunity to have their hair done. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 6 Many positive comments were received about the home from staff, residents and relatives which included the following; “ Everyone knows what they are doing. We work as a team”. “The home is very, very good, it’s the best care home I have worked in. It’s a really warm and pleasant place to work in.” ” I enjoy my job”. “Its alright, they look after you well”. “The staff are nice”. “ I hold Tiled House in high regard”. “Tiled House is a well run care home”. “ I am settled and hope I can stay here”. “ The staff are super, I love them to bits”. “ The staff are a happy bunch”. What has improved since the last inspection? What they could do better: The home must be able to demonstrate that all staff are able to understand and fully care for service users who have specialist needs such as visual impairment and dementia. This includes processes for orientation and to aid better understanding. Care must include adequate activity and stimulation provision. Care plans must include all needs identified for each person examples being; those relating to visual impairment and dementia. Risk assessment and medication systems need some improvement to ensure that they are safe and promote safety to the service users’. Complaints must all be recorded with evidence of investigation and outcomes. Parts of the premises need redecoration and new carpets. Infection control processes need further development and improvement. Staff recruitment processes need some ‘fine tuning’ to ensure that service users are fully protected. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 7 Quality assurance processes need further development and improving. This includes in-house systems and evidence of regular monitoring by senior management. The home has received 35 requirements following this inspection which must be met by the timescales made. If not met this may affect its future risk rating. 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. Tiled House DS0000036816.V320637.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 Tiled House DS0000036816.V320637.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): 2,3,4. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Improvement is needed to ensure that all service users are issued with a contract or terms and conditions containing the required information such as the weekly fee and room number. No service user moves into the home without having his or her needs assessed. EVIDENCE: 17 of 19 completed service user questionnaires confirmed that they received enough information about the home before they moved in. 2 answered no to Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 10 this question and made the following comments; ‘I came in on an emergency client. ‘ Placed here after I left hospital’. Permanent service users’ files viewed held a contract document. However, these documents did not specify the room number or weekly fee applicable to each as they should. It is positive that 17 of 19 completed service user questionnaires confirmed that they have received a contract. 1 service user answered no to this question, 1 other was unsure. It was disappointing that no contract or terms and conditions document was available for one service user who was on a respite stay. Written evidence was available to demonstrate that an assessment of need is carried out for each service user before they are offered a placement at the home and there was a written acknowledgement on three of the four service users files confirming that the home will be able to meet their assessed needs. Tiled House DS0000036816.V320637.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users specialist needs for instance dementia are not always or fully set out in a plan of care. Some development is needed to ensure that the health care needs of each service user are fully met. Medication systems require improvement to prevent risks to service users. Service users are treated with respect and dignity. EVIDENCE: It is positive that a care plan was available on each service user file viewed. Care plans did include a range of needs and areas examples being; personal care, activities and mobility. A shortfall identified was that specialist needs such as visual impairment, diabetes and dementia were not detailed enough to Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 12 allow anyone looking after that person to know exactly what to do. One service user had deteriorated considerably and had been in hospital yet her care plan had not been updated. Feedback from completed service user questionnaires showed the following; 13 confirmed that they always get the help and support that they need. 6 answered usually to this question which is positive. Comments received on this subject included; “ Well looked after” and “ I find the staff very good and willing”. One concern identified was the lack of staff specialist training. For example; at present no staff have received accredited dementia training although one unit in the home is registered to provide dementia care. It is positive however, that the manager has enrolled 6 staff onto the dementia care distance learning course. Similarly, only a minority of staff have received diabetes awareness training even though at least seven service users are diagnosed as being diabetic. A fairly good recording was in place to demonstrate that staff are attending where needed, to service users’ daily personal hygiene needs. It is positive that 17 out of 19 completed service user questionnaires received confirmed that they receive the medical support they need. 2 answered usually to this question. One service user commented; “ The medical support is good I also have Chiropody”. Another service user commented; “ I have changed my GP and am now happy with the service”. Evidence was available to demonstrate that permanent service users weight is taken and recorded on admission and monthly thereafter to allow staff to identify any problems. There was no evidence however, to demonstrate that this was the same for service users accessing respite services Due to inconsistent records it was not always possible to fully track health care services accessed within the home for example; there was no evidence on file for one service user to demonstrate dental assessment. On another whether or not the doctor had actually been informed about her weight loss. Risk assessments were in place but need to be dealt with, with more diligence. For example; one service user’s falls risk score was ticked as being low yet she had a score of 9, which according to the score rating gave an overall risk rating of medium. It was concerning to identify that the full range of risk assessments had not been carried out for one service user who was staying at the home for respite care and that risk assessments had not been updated for one service user whose health had drastically deteriorated. There were positives concerning medications. The senior giving the medication ensured that service users took their medication before signing the medication record. No staff member gives medication unless they have received accredited medication training. No initial gaps were identified on medication records. One service user self medicates and there was a risk assessment on file regarding this. Medication systems do need some improvement to make sure that they are effective and safe for example it was concerning to read the following in the Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 13 night communication book. “ .. Has not had any painkillers in our medicine cupboard for a couple of nights. 2 Co-dydramol given at 1.45 taken out of .. pack again”. Prescribed medication must be available for the service users at all times and other service users medication should not be given to another. There were no photographs on medication records for one new service user and one service user for respite stay. Photographs are an aid to correctly identifying service users to prevent error when giving medication. The fridge holding medication located in the managers office did have a lock facility but it was clear that this lock was not used as a matter of course. Observations of staff and service user involvement were generally positive. Staff were respectful and polite giving choices and assurance where needed. This confirmed by one service user who said;” They let me pick my own clothes in the mornings”. For most service users their preferred name was on file. One relative commented; “ The staff are very caring, helpful and polite”. Toilet and bathrooms doors are kept shut when in use. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. With the exception of the dementia unit service users generally find the lifestyle experienced matches their expectations and preferences. Service users are very much encouraged to maintain contact with family and friends. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing diet in pleasing surroundings. EVIDENCE: It is clear that the home prides itself on its activity provision. A weekly list of activities has been produced and is on display which includes the following; Monday art and craft, Tuesday manicures, Wednesday fun and exercise, Thursday coffee mornings, topical events and memory joggers, Friday bingo. Activities are provided twice a week by the same external providers. Visiting Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 15 providers also visit the home to perform once a month such as singers. A full activity programme is being arranged for the festive season. A vicar visits the home once a month for those service users who wish to partake in a religious service. There was a mixed response from completed service user questionnaires about activity provision as follows; 9 of 19 confirmed that the home always arranges activities that they can take part in, 6 answered usually to this question, 3 said sometimes and 1 did not comment. Comments received about activities were fairly positive one service user said; “ The craft and keep fit lady are both excellent”. “I am willing to have a go at anything”. “ I enjoy bingo would like more of that”. “ Activities are arranged but I prefer not to take part”. One service user said; “ I think if you had some exercises it would help with arthritis”. Activity on the dementia unit needs improvement. Observations showed little interaction with the service users who were all just sitting in their chairs. A service user’s activity record for the whole month of October 2006 just stated; ‘Watching TV’. More structure and one to one sessions are needed. It was clear that the daily routines of the home are arranged around the needs of the residents not the home. Observations showed service users getting up at different times of the morning. One service user said; “ I can get up and go to bed when I like”. The home has an open visiting policy. Visitors were in and out of the home during the inspection. One service user said; “ My cousins come and see me”. Another said; “ I have visitors”. One visitor said; “ I can visit when I want to”. Another relative commented; “ They make me a drink and make me feel welcome”. There was written information available in the home pertaining to external advocates for service users and relatives to contact if they wish. The home keeps the council provided with up to date information to enable service users to vote if they want to. All bedrooms viewed held a range of personal belongings from ornaments to telephones. Two service users had brought their own beds. Questionnaire feedback from service users on meal provision was as follows; 10 of 19 confirmed that they liked the meals at the home, 8 answered usually to this question and 1 sometimes. Positive comments were received about the meals from service users; “ Choice of options to suit personal wishes and tastes”. “ Food is usually good with a good variety”. “ More than enough food”. “ The meals are excellent”. The home has a set menu which is written onto wipe clean boards in the different units. Menus however, are not provided in different formats to aid the understanding of service users accommodated an example being; pictorial. The main meal is served during the evening in the week at lunchtime a buffet type meal is offered. Lunch on the inspection day was assorted sandwiches examples being; ham, cheese or egg on brown or white bread, crisps and salad. Service users who wanted were offered a currant cake. The mealtime on Fern unit was observed. There was a staff member on hand who asked the service users what they would like, gave choices and offered Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 16 more food when they had finished. The staff member encouraged drinks by asking the service users a number of times if they would like another drink offering both hot or cold options. The home does have food intake records to monitor food eaten by service users however, it was surprising that supper is not recorded on these records preventing an audit to be undertaken of any service users true dietary intake. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Improvement is needed regarding complaints processes. Some ‘fine tuning ‘ is needed in respect of protection. EVIDENCE: The Commission has received no complaints about the home. One complaint has been recorded in the complaints folder since the last inspection which was responded to but no longer applies. 14 of the 19 completed service user questionnaires confirmed that they know who to speak to if they are not happy. 5 answered usually to this question. 14 of 19 service users confirmed that they know how to make a complaint, 5 answered usually to the same question. It was concerning to read the following in the homes night communication book; 19.10.06 “ .. complaining when staff did first check about she had been left since 8.30. She did not have her buzzer and a drink of horlicks had been left where she could not reach it”. And Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 18 21.10.06 “Complained to me that she had been told by .. not to put her buzzer on unless it was for something important. N had buzzed at 11pm because she was close to the edge of the bed”. The content of these complaints alone was concerning as they could constitute protection issues, (the incidents should be discussed with the service users social worker during her next review) to add to this although the record of these complaints had been logged in the night communication book there was no evidence of these complaints in the complaints book. The manager confirmed that; “both of the incidents had been dealt with and had been addressed with the staff and service user, but there had been no record made to prove this as there should be”. No allegations or incidents of abuse have been reported to the Commission. The home had available a copy of Dudley Councils protection procedures titled ‘Safeguard and protect’ which is positive however, there was no evidence available to demonstrate that staff had read and signed these procedures. The manager was not able to demonstrate that all staff have received abuse awareness training as they should. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 19 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): 19,24,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is in need of some redecoration and replacement of carpets. Generally service users have comfortable bedrooms although assessment is needed for one who has some specialist needs. Although the home is clean and orderly some improvements are needed to promote infection control. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home is divided into six units within to promote a homely feel. Although it is positive that a number of bedrooms, one lounge, the reception area, toilets and bathrooms have either been redecorated or are in the process of being redecorated the home has decorating needs. The paintwork on corridors and landings need repainting desperately as do some lounge areas. Carpets in a number of corridors have seen better days and need to be replaced. The dementia unit needs some attention regarding colour schemes and fittings to enhance familiarisation and orientation. Better signage on rooms, toilets and bathrooms could be an advantage. Big face clocks in lounges and bedrooms may help enhance orientation regarding day, night and time.. The gardens looked untidy at the time of the inspection however, the manager confirmed that they are shortly to receive the required attention. A number of bedrooms were seen during the inspection. All had service users own belongings in them to personalise and make the rooms feel homely. Service users spoken to confirmed that they liked their bedrooms. One service user said; “Most things in here are my own including the bed and the bedding”. Another service user said; “ I do like my room but I can’t see anything due to my sight. The light is not enough”. With the permission of the service user this issue was raised with the manager who confirmed that she would sort it out. Generally the home looked clean and orderly. Completed service user questionnaires revealed the following; 16 of 19 confirmed that the home is always clean and tidy, 3 answered usually to this question. Comments received included; “ Very clean”. “ Always fresh”. “ Spotlessly clean thoroughly everyday, well done to all”. One service user accommodated at the time of the inspection had contracted an infection whilst in hospital. The manager confirmed that staff were using the correct procedures to prevent transmission of this infection. The inspector however; was concerned that no-one had told her about this infection before she entered the service user’s bedroom. The manager gave an account of a recent bout of flu in the home where service users had some nasty symptoms including vomiting. It was clear that infection control processes at this time must have been effective as the staff were able to contain this flu on one or two units preventing spread to the ground floor units. There were no written processes in place in the service users care plan or the laundry to remind staff how to manage the infection. The laundry is well equipped with commercial appliances. The laundry is separated to allow clean and dirty laundry to be kept apart which is positive. Some shortfalls were identified which need to be addressed to promote infection control. A separate sink is needed to use for staff ‘ hand washing only’. The sink and floor were not adequately clean and require attention on at least a daily basis. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Service user needs are generally met by the numbers of staff provided. The home should be congratulated as 78 of the staff team have achieved NVQ level 2 or above in care. Recruitment processes need some further development. Staff receive induction when they commence employment. EVIDENCE: The home has experienced staffing shortages where agency staff have been used. One relative said; “ The only thing is when there are causal staff ”. The manger confirmed that this situation has improved considerably of late as she has recruited a number of new permanent staff allowing a major decrease in agency staff usage which is good. Staff members spoken to agreed that the staffing situation had improved and that the home is now mostly adequately staffed. Completed service user questionnaires concerning staff availability confirmed the following; 10 of 19 said staff are always available when needed. 9 answered usually to this question. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 22 Staff observed during the inspection were seen to be friendly and caring. It is extremely positive that 19 of the 19 completed service user questionnaires confirmed that the staff always listen and act on what is said”. There were also numerous positive comments received about the staff which included;” The staff are fantastic with them”. “The staff are very nice I can not fault them at all”. “ I like my key worker she is very good”. “ Always very attentive”. “Staff are very caring and helpful”. It is extremely positive that 78 of the staff team have achieved NVQ level 2 or above in care. The files of three new staff and two agency workers were assessed. Most required information was included on files examples being; two written references, an application form, identity and a health declaration form. However, evidence of POVA list checks was not available on all staff files. All that was provided by the Human Resources section was a memo confirming that a CRB had been received. Confirmation that this had included a POVA list check was not mentioned. Similarly. Agency checks did not state if staff CRB was clear or not. Whilst it is positive that a CRB was available for hairdressers and activities persons there was no CRB for the chiropodist who provides unsupervised personal care to service users. It was positive to see evidence to demonstrate that induction processes are in place for new staff. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 23 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): 31,33,35,36,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is a fit person to run and manage the home. Quality assurance processes need development and improvement to ensure that the home is run in the best interests of the service users. Service users financial interests are safeguarded. All but the manager receive frequent supervision. The health and safety of service users is promoted. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager has been approved by the Commission as a fit person to run and be in charge of the home. She has achieved her Registered Managers Award. The manager is very keen to improve the home and keeps herself updated with new guidance. The manager displays good leadership skills and provides direction to her staff. It is positive that the manager has begun a process to self audit the home against the National Minimum Standards for Older People. The manager was able to provide evidence of satisfaction surveys being used to gain views of the service users about the home in general. It is also positive that regular staff and service user meetings are held with records made. Quality monitoring however, needs to be further developed to finalise the self audit mentioned, gain views on the service from relatives and other stakeholders and for the results of all to be published. It was disappointing to discover that the senior manager responsible for this home is not carrying out the required monthly visits as often as he should. Last monthly reports available were dated Feb 06 and Sept 06. Four service users money held in safekeeping were checked against records and balances. One of these service users had not brought any money into the home. The rest were found to be correct with receipts of expenditure and a balance that matched records. Dudley Councils Finance Section carried out a full audit of money within the home including that of service users in August 2006. The outcome of this audit was mostly positive. It is positive that systems are in place within the home to provide staff with regular, formal one to one sessions. The supervision shortfall identified relates to the manager who is not receiving supervision to the required frequency. The kitchen was not assessed during this inspection as Dudley Council’s Environmental Health Department only carried out an inspection on 13 November 2006. Maintenance records and servicing of equipment certificates were assessed and found to be in order. Risk assessments however, for the rotary iron need to be undertaken to reduce/ eradicate risk to staff. Fire training and drill sessions are mostly up to date with forthcoming training booked. Generally, staff training is up to date with the exception of new staff where training has been or is being arranged. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 25 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 x 2 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 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 2 2 x x x x 3 x 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 3 Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 26 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 OP2 Regulation 4,5. Requirement The registered persons must ensure that; All residents are issued with a contract/terms and conditions document – this also to apply to residents accessing respite care. The room number and weekly current fee applicable to each resident be detailed on their contract/ terms and conditions document. This must happen with immediate effect for new residents/ residents being admitted. An audit of all residents’ contracts/ terms and conditions must be carried out and the correct information be detailed within. The charges for respite care must be displayed along side permanent care prices. The registered persons must ensure that the care plan of the resident identified during the inspection with a sensory impairment is updated to clearly state her needs and risks DS0000036816.V320637.R01.S.doc Timescale for action 03/01/07 2 OP7 15(1) 01/12/06 Tiled House Version 5.2 Page 27 3 OP7 15(2)(b) 4 OP7 15(1) 5 OP8 12(1)(a) 13(1)(b) associated with her visual impairment ( when mobilising etc) This must contain instruction to staff to ensure that as much light as possible is provided in her bedroom for example-only use clear light bulbs. The registered persons must 01/12/06 ensure that service users care plans are updated when a change occurs for example; deterioration. The registered persons must 20/12/06 ensure that care plans fully reflect the needs of each resident this to include needs relating to diabetes and dementia (etc). The registered persons must 10/12/06 ensure that a clear audit trail/records are made of all professional health care visits. This to include concise records where it has been communicated to the doctor or other professionals about the weight loss of any resident. 6 OP8 13(3)( c) 13(5) The registered persons must ensure that; Risk assessments are carried out for each resident on admission this to include moving and handling, falls, nutrition, behaviour, and tissue viability. Risk assessments are repeated when there is a change of condition or when a service user is re-admitted into the after a stay in hospital. Risk assessment documentation all reflect the accurate scores and score ratings for example; low, high. 01/12/06 Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 28 7 OP8 12(1)(a) The registered persons must ensure that all residents admitted for respite care are weighed on admission and preferably before discharge. This was communicated to the manager during the inspection. The registered persons must ensure that all staff receive the following training; Accredited dementia training. Diabetes awareness/ care training. Parkinson’s awareness/ care training. Visual impairment awareness /care training. 30/12/06 8 OP8 18(1)(a) 01/03/07 9 OP9 13(2) The registered persons must ensure that; Medications prescribed for residents are available at all times. That under no circumstances are medications dispensed for one resident given to another resident- even if they are the same medication. This was communicated to the manager during the inspection. 22/11/06 10 OP9 13(2) 11 OP9 13(2) The registered persons must 22/11/06 ensure that the medication fridge in the manager’s office is locked at all times. 01/12/06 The registered persons must ensure that a photograph of each resident is attached or close by to their medication record on admission (this particularly applies to respite and emergency admissions). The registered persons must DS0000036816.V320637.R01.S.doc 12 OP9 13(2) 06/12/06 Version 5.2 Page 29 Tiled House ensure that the top of each medication record is fully completed examples being; the doctors name, known allergies or ‘nil known’ where applicable. 13 OP9 13(2) The registered persons must ensure that; The doctor is informed about each resident who is not taking medications that are prescribed to be taken regularly. Medications written on medication records to be taken ‘As directed’ are changed to proper administration instructions for example ‘one twice a day’ etc. The registered persons should add to the homes medication policy instruction for staff on the following; That all homely remedies must be ratified by the resident’s doctor before being given to the individual resident. That where a resident passes way then their medication must be retained within the home for 7 days after. 15 OP12 12(4(b) 16(2(m) (n) The registered persons must ensure that residents on the dementia care unit are provided with adequate activities/ stimulation. And that where needed these can be provided on a one to one basis. Literature and equipment to aid this process must be obtained to enhance the skill and knowledge of staff and enhance activities for residents who have a diagnosis of dementia. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 30 06/12/06 14 OP9 13(2) 30/12/06 22/12/06 16 OP15 Sched 4 (13) 12(4)(b) The registered persons must ensure that food intake records include supper. The registered persons must ensure that menus are produced in a format appropriate to all residents for example pictorial. The registered persons must ensure that; All complaints are recorded in the complaints log. That action taken/ recorded f investigations are recorded with evidence of feedback to the complainant. That the complainant is given the opportunity within a specified timescale to state whether they are satisfied with the outcome/ action taken concerning their complaint. 01/12/06 17 OP15 05/01/07 18 OP16 22(3)(4) 05/12/06 19 OP16 18(1)(a) 22(2) The registered persons must ensure; That the complaints procedure is produced in a format appropriate to all residents pictorial etc. That staff receive complaints training. 01/02/07 20 OP18 13(6) 37(1)(e) 13(6) 18(1)(a) 21 OP18 The registered persons must add to the homes protection referral flow chart the need to report to the CSCI – Reg 37. The registered persons must ensure that all staff receive abuse awareness training. This to include staff reading and signing Dudley MBC protection procedures. 10/12/06 30/01/07 22 OP19 23(2)(f) The responsible person must DS0000036816.V320637.R01.S.doc 01/03/07 Version 5.2 Page 31 Tiled House provide at least two accessible double electric sockets in each bedroom. Previous timescale of 31.3.2005 not met. 23 OP19 12(4)(b) 23(2)(n) The registered persons must enhance the dementia unit in terms of orientation by providing; Large faced clocks. Appropriate colour schemes and signage. 24 OP19 23(2)(d) The registered persons undertake a full audit of the homes redecoration needs. Work needing to be done must be included in their refurbishment programme which must include the following; Corridors/ redecoration and paintwork to include skirting boards and door frames. ( to include area leading to the laundry. Replacing of corridor carpets. Redecoration of Maple and Fern units communal areas. Work to be completed by timescale set. 25 OP24 23(2)(n) The registered persons must ensure that; A referral is made to the sensory impairment team to assess the resident’s ( identified during the inspection) needs and bedroom to ensure that everything needed is being provided to promote this persons independence, health, well being and safety. DS0000036816.V320637.R01.S.doc 10/01/07 01/03/07 01/12/06 Tiled House Version 5.2 Page 32 26 OP26 13(3) The registered persons must ensure; That infection control procedures are available and are on display in the laundry. That information pertaining to infectious diseases (for example MRSA) is available in; The affected residents care plan. The affected residents bedroom. The laundry. 01/12/06 27 OP26 13(3) 23(2)(d) 13(3) 23(2)(d) 28 OP26 29 OP26 13(3) The registered persons must ensure that the chairs in Maple unit are cleaned properly to prevent odour. The registered persons must ensure that; The sink and floor in the laundry are thoroughly cleaned at least daily. Evidence of cleaning schedules is available. The registered persons must ensure that; Mop heads are cleaned on disinfectant cycles daily. That mop heads are left to dry when not in use. 01/12/06 01/12/06 01/12/06 30 OP26 13(3) 31 OP29 13(6) 19(2)(11) The registered persons must 05/01/07 ensure that an additional sink for staff ‘hand washing’ purposes only is provided in the laundry. In the interim risk assessments must be in place. 10/12/06 The registered persons must be able to evidence from records held on staff members files (memo from HR) that a POVA list check has been carried out. That the agency staff have had a POVA check and that this and their CRB was clear. That the hairdresser (SH) is risk Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 33 assessed and that she signs a new disclaimer or that a new CRB is applied for. That the chiropodist provides evidence of a CRB/POVA list check. 32 OP33 26(2) 26(3)-(4) The registered persons must ensure that a nominated person visits the home and least once a month as per throughout Regulation 26 and compiles a written report of their findings. The registered persons must ensure ; That monitoring to self assess the homes performance against all National Minimum Standards for Older People is fully implemented. That questionnaires are used to gain the views of relatives and other stakeholders. That results of all questionnaires are published. The registered person must ensure that the manager receives formal one to one supervision at least 6 times per year. A schedule of supervisions must be produced. The registered persons must ensure that a risk assessment is produced and displayed pertaining to the rotary iron in the laundry. 10/12/06 33 OP33 24 01/02/07 34 OP36 18(2)(a) 15/12/06 35 OP38 23(2)( c) 15/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 34 No. 1 Refer to Standard OP9 Good Practice Recommendations The manager is recommended to audit the documentation of medication administration weekly and maintain a record. It is strongly recommended that two staff sign all handwritten medication records to verify that information transferred from medication containers/ prescriptions has been done correctly. 2 OP9 Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 35 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. Extracts may not be used or reproduced without the express permission of CSCI Tiled House DS0000036816.V320637.R01.S.doc Version 5.2 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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