Inspection on 12/07/07 for Weatherdale Unit

This inspection was carried out on 12th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Weatherdale Unit 16/06/06

Weatherdale Unit 09/12/05

Weatherdale Unit 05/07/05

Weatherdale Unit 20/10/04

Weatherdale Unit 07/04/04

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

CARE HOMES FOR OLDER PEOPLE Weatherdale Unit Weatherdale Unit 31 Weather Oak Harborne Birmingham B17 9DD Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 12th July 2007 09:00 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 Weatherdale Unit DS0000035597.V338276.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. Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Weatherdale Unit Address Weatherdale Unit 31 Weather Oak Harborne Birmingham B17 9DD 0121 427 1607 0121 678 3745 tina.walston@birmingham.gov.uk Not known Birmingham City Council (S) 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) Vacant Care Home 10 Category(ies) of Dementia - over 65 years of age (10) registration, with number of places Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The unit is registered to accommodate 10 adults over 65 who are in need of care for reasons of dementia and associated challenging behaviours. Registration category will be 10 DE(E) That minimum staffing levels for the residential unit are maintained at 2 care plus a senior member of staff throughout the waking day of 14.5 hours Additionally to the above minimum staffing levels, there must be 1 waking night care a senior on waking or sleeping-in duty for respite care users Levels of staffing must be increased appropriately to reflect the numbers of day care service users Care/shift manager hours and ancillary staff should be provided in addition to care staff 16th June 2006 Date of last inspection Brief Description of the Service: Weatherdale is a ten bedded respite and day care unit that is situated within a purpose built, local authority residential home. The unit is staffed and managed separately from the rest of the home and is registered separately with the Commission. It is funded and run jointly by the Health Service and Social Services and is designed to offer a variety of support services for carers/relatives looking after older people who have dementia and associated challenging behaviours. Support can be in the form of day care, overnight stays, weekend breaks or short stays. Weatherdale is located in a quiet, residential cul-de-sac off a main road in Harborne. The unit is within easy access of public transport routes as well as all local facilities including shops, churches, library and swimming baths. It is a single storey unit with its own entrance with a coded lock. The unit comprises of lounge/dining area with a small kitchenette, quiet lounge, office space, laundry, fully equipped bathroom, two toilets and 10 single bedrooms. Lawns surround the building and there is a small, secure paved area with seating and flowerpots that residents have access to. There is limited parking to the front of the building. The unit currently has a range of charges for attending Weatherdale. Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 5 They are as follows Breakfast 75p Day care £3.30 (lunch) £1.45 (tea) Night Care £7.33 Overnight Stay £9.23 One week respite £64.65 These charges are payable weekly or monthly and must be paid to Birmingham City Council. Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place over one day. We have used a variety of methods to make judgments about the service within the body of this report. We spent time talking to the manager, staff and some of the service users to find out their experiences of the care they give and of the care they receive. We also looked at three service user files in detail as part of our case tracking process. This enables us to make decisions about whether the unit is meeting the needs of its service users. Staff files were also looked at to ensure that the unit is continuing to recruit people in a manner that safeguards service users and to see if staff are continuing to receive all of the training they need to keep their knowledge and skills up to date. In addition to this we looked around the unit to see the improvements that have been made. We have also used information given to us from the manager in the unit’s completed Annual Quality Assurance Assessment (AQAA). We have included information from this assessment in the report where appropriate. The inspector would like to thank all of the staff and service users for their time and hospitality throughout the inspection. What the service does well: What has improved since the last inspection? Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 7 We found that the unit has been redecorated and refurbished throughout. The provision of new furniture has made the unit feel more relaxing and a more pleasant place to be. Staff have undertaken training in dementia care and medication administration. This has further enhanced their knowledge and skills when caring for service users. There is a new system in place for planning activities for service users. The system uses the individual preferences of service users and it always planned on weekly basis to ensure that it suits the needs of the service users who are using the unit for that week. The manager has raised the visibility of the complaints procedure and makes sure that all service users have copy of it when she completes their initial assessment. Staffing levels have improved and now offer service users the opportunity for one to one care if this is needed. Qualified nurses work alongside the care staff to offer clinical support to the unit but they are not directly responsible for the care of the service users. The unit now has a full time manager in post who is giving the unit direction and improving the service for people with dementia. It was very pleasing to find that 34 out of the 36 outstanding requirements have been addressed and have been removed from this report. What they could do better: Some of the people using this service have been transferred there following the closure of another unit. The manager and team leaders need to review all of their documentation to ensure that it is up to date and gives a true reflection of their needs. Medicines that require cold storage must be kept at recommended temperatures. The unit has a fridge with a thermometer but is not recording the temperature on a daily basis. This needs to happen so that the people who use this service can feel confident there medication is being stored appropriately. Some of the people who attend the unit have their medication on a “PRN” basis, this means “as required”. The manager must make sure that for these people a care plan clearly details the circumstance in which this medication is to be given, the frequency of the administration and also a method for recording the medicines effectiveness once given. Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 8 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. Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 9 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 Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 Quality in this outcome area is good. People who may use this service are given enough information about it to enable them to make a choice about using it. They can feel confident that their needs will be assessed in full. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The unit has produced as Statement of Purpose and a Service user guide. Each of these documents is given to prospective service users when the initial home visit is conducted. The unit has an open referral policy which means that anyone can refer themselves to the unit for care and respite breaks. The Service User Guide clearly details the costs to each person and outlines the function of the unit. Once a decision has been made to accept the service a trial visit is arranged to give service users the opportunity to test drive the service. This trial period can last for four weeks during this time the unit will conduct an in depth assessment of each individuals needs. Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 11 The unit does not however give service users a contract or a statement of terms and conditions. This document would clearly show service users the cost of the service to them, the role and responsibility of the registered provider (Birmingham City Council) and the rights and obligations of the service user. The manager did say that they are waiting for new contracts from the Council and once this happens they will make their own that specifically reflects the service Weatherdale Unit offers. Each service user has their own assessment, three service users files were seen as part of the case tracking process. Two of the service users had been transferred to the unit following the closure of the day care they attended. We found that their assessment documentation was not always accurate and was in need of review. Another service users file was seen it was pleasing to see that the assessment was detailed and offered a good insight into the individual care this service user required. All of the assessment documentation has been updated since the last inspection. Service users and there families are involved throughout this process and are encouraged to complete a “personal information” assessment. This assessment forms part of a life history for the service user and also details individual likes and dislikes about how they want their care given. The unit also offers carers an assessment of their own to ensue that they are getting all of the help and assistance they require in order to look after the person with dementia. Since the last inspection greater numbers of staff have attended training in Dementia care, this will build upon skills and existing knowledge and make sure that the care service users receive is based upon current best practice. The manager said that there are plans in the near future for all staff to receive more training in person centred care and planning. There are plans to introduce the system of Client allocation in the neat future. This system will help staff focus upon a small group of service user throughout their stay to ensure that all of their needs are being met. Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 12 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. People using this service can be confident that their health needs will be met and they will be treated with respect and dignity at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users have a plan of care. Improvements have been made to this process since the last inspection. The manager has taken steps to introduce a falls risk assessment for each service user. This means that any risk of falls is identified and a plan to reduce that risk to the service user is recorded. We looked at three service users files and found that some information needs to be updated in order to reflect service users needs. For instance when reading the daily notes for one service user it had been recorded that they had fallen over and that staff were now using the wheelchair for transfers. The falls risk assessment had been reviewed but made no mention of the recent falls or the use of a wheelchair. It states “continues to elevate legs and walk round with a zimmer frame”. Another service user had no falls risk assessment at all. This was discussed with the manager who said that some of the service users had Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 13 been transferred to their care from another day service that had closed. They had “adopted” the paperwork for each of these service users. The manager has agreed that all of the service users who have been transferred into Weatherdale Unit’s care will have a review of their assessments to ensure that they are all up to date and provide a true reflection of their needs. A nutritional risk assessment has not been formally introduced into the paperwork for each service user but the manager was able to show that the screening tool is available on the unit and that they are currently waiting for training in how to use the tool from the dietitian. Other care plans were good and showed that the staff are beginning to grasp the person centred planning aspects of care. For example one service users care plan indicated that she liked her food cut up into small pieces so that she could eat it because she only had a bottom set of teeth. Staff had recorded the preferred rising and retiring times of service users. Service users preference to the gender of their carers has also been given consideration. For instance one lady’s plan stated that she preferred a female carer to help her with personal hygiene and helping her to get dressed. This enables them to offer a more flexible service based upon service users needs rather than the needs of the organisation. The manager said “most of our clients don’t sleep at night and that’s fine, they are encouraged to do what they want to do” All service users keep their own GP’s when they attend Weatherdale Unit. The manager said that in some cases where service users stay for a week’s respite and they are out of the catchment area for their own GP they will be temporarily registered with the local GP during this time. All nursing care remains the responsibility of the district nursing service. The nurses who are employed on the unit are there for clinical support only and do not offer nursing care. Medication practices have also improved, the manager said that all of the senior staff have now completed the Safe Handling of Medicines course, this has given them added skills and knowledge to be able to administer medication safely to service users. The manager said that the trained nurses will administer medication at times. There are good systems in place for the receipt of medicines. Service users are asked to provide their medication upon their admission to the unit, this information is then copied onto a medication administration record sheet (MAR) ready for administration. Any conflicts of information about medication are discussed with the service users GP to ensure that they are receiving their medication as prescribed. There are a couple of areas for improvement, staff need to be recording the daily record of the drugs fridge to ensure that all medicines requiring cold storage are kept at recommended temperatures. And for those service users who require medication PRN “as required” a care plan is needed to guide staff about when the administration of such medication is appropriate, the Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 14 frequency with which it may be administered and a method for recording its effectiveness. Throughout the inspection service users were seen to be helped in a sensitive manner by care staff. They spent time with service users encouraging them to talk about their needs, they did not rush them and gave them plenty of time to answer questions. Staff were seen to be knocking doors to service users bedrooms before they entered and when service users were using the toilets. One relative said “the staff are fantastic, they are brilliant”, one service said “they never rush me but they know what I want”. When asked if staff looked after him well he answered “always”. Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 15 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. People using this service are encouraged to take part in activities and to maintain family contacts. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Every service user is asked how they like to spend their day and about the hobbies and interests they each have. The manager explained that rather than have s set programme of activities, they have taken a more relaxed approach to activity provision. A meeting takes place every Sunday with the care team to decide on activities for the coming week. The staff will consider all of the service users who are due to attend that week and look at their personal assessments. The information about individual hobbies and interests is then used to plan for the week ahead. This creates a more person centred approach to activity planning. Relatives are encouraged to spend time away from the unit. The emphasis for relatives is to have a break from caring. The manager also said that they help support carers by having regular carer support groups, this gives relatives the opportunity to talk to other people in a similar situation. Relatives are involved Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 16 in all aspects or care planning and are often asked to complete the “personal assessment” with the service user. Meals are provided at extra charge for those service users who attend on a daily basis. The cost of meals for those who are using the week’s respite facility are included. Meals are supplied from the kitchen in the adjoining residential home. Service users appeared to enjoy the food on offer. It was pleasing to see that the staff also join service users for meals. This helps all service users relax and enjoy the company of staff whilst eating their meals. This arrangement also gives the staff the opportunity to observe service users and identify any issues they may be having during meal times, such as the need for adapted cutlery, larger plates or a change in their dietary preference. The unit is also able to cater for specialised diets where needed. Weatherdale Unit DS0000035597.V338276.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 good. People using this service are encouraged to express their views, they can feel confident that they will be listened to and their views acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The unit has a complaints policy and procedure. All service users are given a copy of Birmingham City Council’s leaflet “Your right to be heard” when they begin using the service. The home has received no complaints for over twelve months and the manager said that they work very closely with both service users and their carers to make sure that there is an open channel of communication so everyone feel able to discuss any concerns they may have. There is a regular carers meeting held at the unit that encourages people to make suggestions, air their views and give compliments. The unit has received a lot of compliments about the service and the care that they give. Relatives said “I would like to compliment the staff on they way my relative was looked after, knowing he was in safe hands”. “thanks to all the staff for the wonderful care at Weatherdale”. There is a copy of the local authority guidance for the Protection of Vulnerable Adults on the unit. The manager said that staff training has not yet been Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 18 organised for all staff but this is being addressed. This must be done so that service users can feel that they are being protected from harm and abuse by staff with sufficient knowledge to do so. Service users also need to feel confident that staff will act appropriately if an allegation of abuse is made, further training will ensure this happens. Weatherdale Unit DS0000035597.V338276.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, 26 Quality in this outcome area is good. People using this service can be assured that it is well maintained, clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the unit was undertaken, since the last inspection the there has been much redecoration and refurbishment. The lounge and dining area have benefited from new furniture and provide a nice relaxing place for service users to sit and eat their meals. Bedrooms have also been redecorated and some of them have had new carpets, this makes the rooms feel more welcoming. New soft foam mattresses have also been provided reducing the risk of pressure sore development to service users. In each bedroom there is a lockable facility for Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 20 service users to store valuables should they wish to do so. Key are available for individual bedrooms should service users want to use them. The toilet facilities for the unit have also been improved, the partitioning is now from floor to ceiling and offers more privacy to service users when using the toilet. Each bedroom has also been supplied with a commode for use during the night. There is a small kitchen facility on the unit where staff can make drink and snacks when needed. The kitchen is in need of refurbishment and this was also highlighted in the last inspection report. The manager said that this is due for an upgrade in the next twelve months. The laundry and the sluice facility have both been issued with key pad locks, this has reduced the risk of service users entering these rooms where they may be placed at risk. The laundry is small but is sufficient to meet service users needs, staff have access to gloves and aprons and liquid soap is freely available for hand washing. The manager also said that staff have recently had training in correct hand washing techniques. The sluice has been fitted with a macerator and a pot washer to ensure that commode pots are cleansed effectively. Some of the staff are currently taking part in infection control training via distance learning. All of this will help staff to reduce the risk of cross infection to service users Weatherdale Unit DS0000035597.V338276.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. People using this service can feel confident that there are sufficient staff on duty to meet their needs and that they have been recruited in a manner that safeguards their interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The unit is staffed by both Birmingham City Council and the Birmingham and Solihull Mental Health NHS Trust. The qualified nurses are on the unit to provide clinical support to the care workers and are not responsible for the overall care of service users during this time. There are usually four members of staff on duty, this includes the manager. In the very near future the arrangements for night time cover will also be changed. A trained nurse will now be on shift throughout the night offering clinical support to staff. This is in addition to the waking night shift and the on call carer. Staffing has been increased in this way to allow service users more direct care and attention. The manager said that service users with dementia are often awake throughout the night and it was felt that extra staff would help service users feel more settled during this time. Since the last inspection an administrator has been employed to help with the day to day running of the unit. Staff files are also now available for inspection. The manager has worked hard to ensure that all the required information Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 22 needed for these files is in place. It was pleasing to see that a recently appointed care worker’s file had all of the required information and the unit is recruiting people in way that safeguards service users. This includes making sure that Criminal Records Bureau (CRB) disclosures are completed and checks against the Protection of Vulnerable Adults list (PoVA) are also done. There were records to show that the new workers have received an in house induction alerting them to the fire policy, health and safety issues and other related topics. There were no records how ever that new staff receive an formal induction after this that conforms to Skills for Care Induction standards. It was pleasing to see that in their AQAA document the manager has indicated that 8 out of the 11 care staff have now completed their National Vocational Qualification (NVQ) the remaining 3 staff are currently completing their NVQ. The unit also offers specialist placements to nursing students. During the time they spend on the unit all students are fully supported and encouraged to learn as much as they can about dementia and the service users. Weatherdale Unit DS0000035597.V338276.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, 38 Quality in this outcome area is good. People who use this service can feel confident that it is run in their best interests. The manager ensures that the health and safety of service users is promoted at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the deputy manager has been promoted to manager. During this time she has worked hard to address the outstanding requirements from the last inspection and to improve the service they provide. The manager said that she has a “consistent approach in promoting and supporting staff for over 13 years and enjoying seeing staff develop through supervision, coaching and effective leadership”. She is currently going through the registration process with the CSCI. Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 24 The quality assurance system continues to be developed, the manager completes monthly audits of care plans, medication and health and safety checks. In addition to this they regularly seek the views of service users and their carers. The last survey revealed some dissatisfaction with the transport arrangements, which the manager has now addressed. The unit does not handle any money on behalf of service users. There is a lockable facility in each bedroom should service users wish to lock their money and valuables away safely. As in previous inspections the copies for servicing of electrical wiring, fire alarm system, gas safety and legionella testing were all kept on the adjoining unit. It was pointed out during the last inspection that the unit must have its own copies of these as they are registered as a separate service. Staff training is improving but as with the last inspection there was little evidence to show that staff have received training. The manager did say that this was because the training team can be very slow in sending out the certificates to attendees. Staff did say that they have received training recently in first aid. This means that service users benefit from a qualified first aider on every shift. Some staff are also in the process of completing their Infection control training via distance learning. The manager also said that they are currently working on a training matrix that would highlight when staff are due for training so that their knowledge and skills are kept updated. Weatherdale Unit DS0000035597.V338276.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Weatherdale Unit DS0000035597.V338276.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 OP7 Regulation 14 Requirement Service users care plans and risk assessments must reflect their changing needs to ensure that they are getting the most appropriate care. The quality assurance system will need further development in order to demonstrate that the service is run in the best interests of the service users. Timescale of 30/04/06. Part met Service users must be confident that all staff have received a recent fire drill. The home must be able to demonstrate which staff have taken part in each drill. (previous timescale of 30/07/06 not met) Timescale for action 01/08/07 2 OP33 24 01/10/07 3 OP38 23(4)(e) 01/08/07 Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP2 Good Practice Recommendations Service users must receive a statement of terms and conditions when they agree to use the service. This will clearly show the fees they are expected to pay, the role and responsibility of the provider and the rights and obligations of the service users. Service users nutritional screening should be recorded in their service user files along with a risk reduction plan where needed. Service users who require medication on a PRN basis will need a care plan that shows staff the circumstances in which this type of medicine is to be administered. It is recommended that the treatment room temperature and the drugs fridge temperature are recorded on a daily basis to ensure that service users medication is being stored safely. Greater numbers of staff must receive adult protection training so that service users can feel confident they will be protected from abuse at all times and staff will act appropriately if an allegation is disclosed to them. It is recommended that a shower room be installed on the unit to give service users more of a choice when bathing To enhance the facilities for residents it is recommended that an additional toilet be installed. It is recommended that copies of the maintenance certificates are to be kept on the unit ready for inspection at any time. The unit should seek the advice of the fire department for the provision of equipment that keeps a door open but will close automatically in the event of a fire. This will mean that staff are no longer using wedges to prop open doors and service users can move freely around the home. 2 3 4 OP8 OP9 OP9 5 OP18 6 7 8 9 OP21 OP21 OP38 OP38 Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Weatherdale Unit DS0000035597.V338276.R01.S.doc Version 5.2 Page 29 - 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. 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