Inspection on 16/06/06 for Weatherdale Unit

This inspection was carried out on 16th June 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

Weatherdale Unit 12/07/07

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 Ann Farrell Unannounced Inspection 16th June 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Weatherdale Unit DS0000035597.V299833.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.V299833.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 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) Birmingham City Council (S) Vacant Care Home 10 Category(ies) of Dementia - over 65 years of age (10) registration, with number of places Weatherdale Unit DS0000035597.V299833.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 9th December 2005 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. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 5 At the time of the inspection there were no minimum standards available for day care therefore only the residential provision was inspected. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection for Weatherdale for the year 2006/2007. The inspection was undertaken on an unannounced basis over one day commencing at 8.15am on 16th June 2006. Currently the deputy manager, who was off duty, is managing the home. However, she came into the home for a brief period to provide information on the developments since the last inspection. The senior carer on duty was present for the duration of the inspection. The inspection process included a tour of the home, inspection of records and documents relating the management of the home and staff. Case tracking of resident’s records was undertaken to determine care of residents from the time of admission. The senior carer, three members of staff, approximately five residents and two relatives were spoken to during the course of the day. A number of residents were unable to communicate verbally. What the service does well: Weatherdale provides a unique service for residents who suffer with dementia and challenging behaviour, which is in high demand. This provides support to carers enabling the resident to remain in their own homes. They provide flexible packages of care, which are person centred and may be accessed in times of crisis. All facilities are based on the ground floor and are easily accessible and all bedrooms provide single accommodation. The home hold regular monthly meetings with carers to provide support, advise and any information they require. Relatives spoken to on the day of inspection appreciated this service. Feedback from relatives was positive. One relative stated, “The staff support us both physically and emotionally, they are like part of the family now- they deserve 20 out of 10.” Another relative stated staff were pleasant and cheerful and always welcomed residents when they came to the unit. Residents stated they liked it on the unit and staff were good. “They do anything you ask.” Staff had worked closely with some relatives in respect of the care of a resident from a different culture to determine how to meet their needs. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 7 The staff group are from a variety of cultural backgrounds reflecting the resident group. What has improved since the last inspection? What they could do better: There are some areas that require redecoration and the manger stated there are plans to re-decorate, provide new flooring and beds later this year. The medication system needs to be further developed to ensure a fully robust and auditable system. The arrangements for staffing need to be reviewed to ensure there are adequate staff on duty at all times to meet residents needs in an individualised manner. The arrangements for activity and stimulation of the residents needs to be reviewed, suitable plans put in place and implemented to meet residents needs. The assessment and care planning system needs to be further developed to ensure a comprehensive system is in place and all staff are aware of the action required to meet residents needs. Records in relation to staff recruitment and staff training should be available in the home for inspection. Regular staff supervision and staff meetings must be undertaken to ensure staff receive appropriate support. Please contact the provider for advice of actions taken in response to this Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Weatherdale Unit DS0000035597.V299833.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.V299833.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 6 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home has information about the services and facilities available for prospective residents, but they will require updating and further development to reflect the services available. There have been improvements in the pre admission process, but further development of the documentation is required to provide staff with the information required to meet resident’s needs effectively and in a consistent manner. EVIDENCE: Weatherdale provides care to residents with dementia on a respite, overnight or day care basis in order to provide support to relatives or carers. Referrals to the unit are usually taken from health or social care professionals and the unit is able to meet a variety of needs. Since the last inspection the assessment process has changed and staff now go out to visit residents in their own home. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 11 This will provide the opportunity to obtain information from relatives and carers about the prospective residents needs. A relative was visiting at the time of inspection and on discussion they stated that a member of staff and a community psychiatric nurse had visited them prior to using the service and he had been given some information. On inspection of the assessment records they lacked information and this area needs to be developed further in order to provide comprehensive information about prospective residents need. This will ensure the unit is able to meet individual residents needs in a consistent manner. Information available for residents and their representatives, but it was found to be inaccurate in some areas and lacked detail. This will need to be further developed. Also the statement of purpose and service user guide should be stand-alone documents. On discussion with some staff it was apparent that they had undertaken a range of basic training, but had not undertaken specific training in respect of caring for people with dementia. Weatherdale Unit DS0000035597.V299833.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Care plans need to be developed further to ensure that all staff are aware of residents needs and they are met in a consistent manner. Some areas in respect of individualised care privacy need to be addressed. There were some improvements in the medication system but further work is required to ensure it is fully auditable and demonstrate that residents are receiving the medication prescribed by the G.P. EVIDENCE: The deputy manager stated that they had been re-structuring care plans since the last inspection. On inspection of a sample of records it was noted that there was no care plan for one resident and the others were lacking in detail and in some cases were not personalised. In one instance the staff had obtained a core care plan for a person from an ethnic minority group, but they had not utilised the information to personalise a care plan for the resident. However, it was stated that they had worked closely with the family for a few weeks to ascertain all the relevant information required to meet the resident’s needs. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 13 On discussion with a member of the family they stated staff were very good and had provided both physical and emotional support “ some of the staff are like part of the family.” Although care plans had been reviewed regularly they had not been updated to reflect the current care needs of residents and the action required by staff to meet the needs. Without care plans it cannot be guaranteed that resident’s needs are met in a consistent manner. This area was discussed with the nurse on duty who has taken responsibility for developing the tools for assessment and care planning. As the residents are only in the unit for short periods they retain their own G.P. and access community health services from home and staff would liaise with them if required. If there were an emergency whilst the resident was on the unit appropriate action would be taken. On inspection of resident’s records there was no evidence of a nutritional assessment or record of weight. This area will need to be addressed. Staff receive medication from relatives when residents enter the home and any medication remaining is returned with them when they leave. Records are kept of medication entering and leaving the unit and on inspection it was found to be generally satisfactory and was auditable. However, the medication for one resident who spends considerable periods in the unit was not auditable. The staff were advised that they would need to record the amount carried over from previous months on the MAR chart at the beginning of each month in addition to any medication that they receive into the home. Other areas that need to be addressed include: the trolley must be secured to the wall when not in use and review the system for obtaining medication as there were times when medication was not available for administration. The unit has an oxygen cylinder available for use, but oxygen was not prescribed. Also there was no policy about its use and there was no evidence that staff had completed accredited medication training. During the inspection staff were pleasant and helpful. The relative stated that staff always welcomed residents when they arrived on the unit, however in some instances staff appeared to be task orientated and there was a lack of attention to individual needs. It was also noted that waste bins are located in the large toilet and a member of staff entered the toilet to dispose of incontinent pads when a resident was using the toilet. This infringes on residents privacy and this are will need to be reviewed. Weatherdale Unit DS0000035597.V299833.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The meals offered are of a satisfactory standard and enjoyed by residents. There is an open visiting policy and monthly meetings with carers to provide support. The activities programme needs to be reviewed, updated and arrangements made for it to be implemented. EVIDENCE: Residents attend Weatherdale on a respite, overnight or day basis and they are free to wander around the unit as they wish. On discussion with relatives they stated they were able to visit if they wished and some would accompany the resident to and from the unit. They found the staff pleasant and cheerful. On discussion with residents they stated “Its very nice -very friendly here.” Other residents stated they could do as they wished “We can please ourselves. The staff are very friendly and helpful- they do anything you ask.” Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 15 Senior staff have a monthly meeting with carers, which is well attended. On discussion with relatives they stated that the meetings were very useful and staff provided advise and they were able to discuss any issues or concerns. The unit has a programme of activities, but the deputy manger stated they have had problems implementing it due to staffing levels, but they are working on this area in order to improve it. On inspection of records there was some recoding in respect of interests and hobbies, but is not consistent. Staff also record activities with the level of the residents well being. However, there were some discrepancies noted in the recording and it was suggested that staff might need some training in this area. On discussion with staff they confirmed that the level of activities was variable and stated they need some more resources in respect of craft equipment. The home receives the main meals from the residential home. On discussion with residents they stated they enjoyed the meals one stated “ the food is very good.” On the day of inspection the meal was hot and tasty. All residents ate the meal and stated it was good. Staff were available, but some spent long periods in the kitchen doing the washing up whilst the meal was in progress. It is recommended that this be reviewed to ensure that residents are supervised at all times during meals. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The unit received few complaints and relatives felt able to raise any issues, but were not aware of the procedures in place. Systems in place safe guard residents. EVIDENCE: The home has a complaints procedure. They have not received any complaints, but have received a number of compliments since the time of the last inspection. The Commission have not received any complaints about the home. On discussion with a relative they were not aware of the complaints procedure, but felt that if they had any concerns they would speak to the manager and it would be addressed. The manger should ensure that all relatives are aware of the complaints procedure. The unit has a copy of the vulnerable adults guidelines and on discussion with some staff they were aware of the procedure in the event of any allegation of abuse. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The unit is generally well maintained and there are plans to undertake some decorating and refurbishment later this year, which will enhance the environment for residents. EVIDENCE: Weatherdale is a single storey ten-bedded unit, which is attached to a large residential unit. The unit was clean, warm and generally well maintained. Parking is available in the main home and there is a small garden area for residents with potted plants and seating for when the weather permits. There are two sheds for storage in the garden and one that is used for the storage of garden equipment was not locked plus a broken umbrella was waiting to be removed. There is one combined lounge dining room and a small quite room, which were pleasantly decorated and furnished. Since the last inspection the quiet room Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 18 has been cleared to enable it to be used by residents if they wish. There are ten single bedrooms with wash hand basin, call bells and locks to doors. All rooms are adequately furnished and commodes have been replaced since the last inspection. The deputy manager stated that there are plans to replace flooring in bedrooms and corridors, replace the beds and undertake decorating later this year. Bedrooms do not have lockable facilities in order to provide space for the storage of medication or valuables. Call bells were not always accessible to beds, some doors were propped open and some were not closing properly due to carpeting. These areas will need to be addressed, as they pose a fire risk. The fire officer has recently visited the home and there are some issues that need to be addressed. There is one large assisted bathroom, which is equipped with a parker bath and it was noted that the curtain rail had fallen down. Residents would benefit from an additional bathroom with a shower facility to provide a choice. However, the inspector is aware that due to the size and layout of the unit this would be difficult to accommodate. The unit also has a hoist for moving and transferring residents if required. There are two toilets with hand grab rails, but they are not partitioned from floor to ceiling. If the maximum number of residents (12) were on the unit this number of toilets could prove inadequate and it is recommended that consideration be given to the addition of an extra toilet. The inspector is aware of the difficulty of accommodating this. Rooms are individually and naturally ventilated and windows are provided with restrainers. All areas are centrally heated, but controls to the radiators cannot be accessed by residents to adjust the heating in individual rooms. Hot water outlets have thermostatic valves fitted to control the temperature of hot water to reduce risks from scalding. There is a separate laundry, which is adequately equipped and a separate room is used for the storage of cleaning materials. During the inspection it was noted that they laundry room was not locked when unattended, there were no staff hand washing facilities in the sluice and staff were noted to be walking around the unit with gloves on. Staff should remove gloves and wash hands after dealing with incontinence or infected material for good infection control procedures. The home has a small kitchen and the doors to kitchen units had been replaced, but some of the carcasses and worktops were damaged and will need replacement. The deputy manager stated that they had requested a kitchen to be fitted. A new fridge had been purchased and temperatures were being recorded regularly, but they were above the safe range. It appears that they are checked in the evening and it may be that the fridge has been opened on a number of occasions. It is recommended that the temperature be checked at Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 19 another time of the day and if it is still above recommended limits the manufacturer contacted. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Staffing levels are not always maintained to adequate levels. Records were not available to demonstrate robust staff recruitment and staff training although discussion suggested that these areas were adequate. EVIDENCE: Staff in the home are made up of staff from the Primary Care Trust and Social Care and Health and at the time of visiting there was a senior carer and two care staff on duty. Examination of duty rotas indicated that there are usually two care staff and a senior member of staff on duty. The conditions of registration indicate there should be two care staff plus a senior carer in addition to the care/shift manger. It would appear that the conditions of registration are not being adhered to. If the manger wishes to change the conditions of registration a written request must be made to the Commission indicating the rationale. The unit are in the process of recruiting staff and have appointed two new care staff to commence employment, but are waiting for the relevant checks to be undertaken. They are currently advertising for a senior carer and an administrator. The deputy manager stated they were developing staff files in order to demonstrate the recruitment process, but they were not in place. Records of recruitment must be made available at the individual premises Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 21 unless an alternative agreement is made in writing with the Commission. No new staff have commenced work on the unit since the last inspection, but the training department of the Local Authority undertakes induction training centrally. Over 50 of care staff had completed NVQ level 2, but records were not available to demonstrate this. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Currently there is no registered manager and the deputy is taking control, but arrangements will have to be made for a permanent manger, who is registered with the Commission to run the home. There have been improvements in the systems for dealing with resident’s monies. Further work is required in respect of formal staff supervision, staff meetings and general support for staff. A quality assurance system also needs to be developed. EVIDENCE: Currently there is no manager in post and the deputy manager is taking charge. The Commission has requested information in writing regarding the management arrangements for the unit. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 23 On discussion with staff there appears to have been some improvement in morale since the last inspection. On discussion with staff it was stated that formal supervision was still not occurring on a regular basis, staff meetings were occurring intermittently and some staff did not feel supported. All residents/day care clients are only on the unit for short periods and the unit only hold small amounts of money or valuables on their behalf. On inspection of records it was noted that there had been some improvements in the system, but all deposits had not been recorded. Staff must ensure all deposits are recorded to enable clear auditing. On inspection of the comforts fund, which is used for the benefit of residents, it was noted that purchases had been made for items such as stationary and a staff taxi to the coroner’s court. This is not appropriate and must be refunded. Currently there is no formal quality assurance process. A carers meeting is undertaken each month and it was stated that they are developing questionnaires for staff and relatives to obtain feedback. On discussion with one relative it was stated they would appreciate some feedback about the time their relative spent on the unit. Records of visits undertaken by the team manger are forwarded to the Commission. The unit retains a record of servicing of some equipment e.g. electrical appliances, the nurse call system, fire extinguishers, the assisted bath and hoists, but other records are retained in the main home. The unit will need to obtain copies of other servicing such as the electrical wiring, fire alarm system, gas safety certificate, legionella testing, water temperatures as they are registered and inspected as a separate facility. Staff stated they had undertaken a range of training, but there was no evidence to demonstrate this. Evidence of staff training must be available for inspection and the manager must ensure all staff undertake at least two fire drills each year plus a first-aider must be on duty on each shift. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No 1 2 3 4 5 6 Score ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 Weatherdale Unit 2 3 2 3 3 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X 2 1 X 2 Version 5.2 Page 25 DS0000035597.V299833.R01.S.doc Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The registered person must review and update the statement of purpose to ensure it provides accurate and update information. The registered person must review and update the service user guide to ensure it provides accurate and update information and it must be a stand alone document All residents should be provided with a statement of terms and conditions at the point of admission to the unit. Timescale of 30/03/06 not met. The registered person must undertake a review of the documents used for recording assessments to ensure it covers all areas outlined in standard 3 of the National Minimum Standards and provides comprehensive information to enable staff to meet resident’s needs in a consistent manner. The registered person must ensure all staff undertake training in respect of caring for residents with dementia DS0000035597.V299833.R01.S.doc Timescale for action 30/10/06 2 OP1 5 30/11/06 3. OP2 5(1)(b) 30/10/06 4. OP3 14 30/08/06 5 OP4 18(1) 30/09/06 Weatherdale Unit Version 5.2 Page 26 6 OP7 15 7 OP8 14 12(1) 8. OP9 13(2) 9 OP9 13(2) 10 OP10 12(1) 12(4) The registered person must review the care planning process to ensure that records are personalised to residents, outline in detail the action to be taken by staff and cover all needs in a holistic manner. Timescale of 30/12/03 not met. The registered person must ensure a nutritional assessment is undertaken and residents are weighed on admission to the unit and they are reviewed on a regular basis. The registered person must ensure a robust system in respect of medication to include: • The trolley must be secured to the wall when not in use. • Record the amount of medication carried forward to a new MAR chart. • Review the system for obtaining medication to ensure residents are not without prescribed medication. The registered person must: • Draw up a policy in respect of the use of oxygen that is not prescribed and forward it to the Commission. • Ensure all staff administering medication have undertaken accredited training a record is retained in the home for inspection. The registered person must: • Review the arrangements for disposal of waste to ensure it does not impinge on resident’s privacy. • Review working arrangements in the home to ensure an individualised approach to care is DS0000035597.V299833.R01.S.doc 30/11/06 30/07/06 30/06/06 30/11/06 15/07/06 Weatherdale Unit Version 5.2 Page 27 11 OP12 16(2)(m) (n) provided. The registered person must undertake an assessment in respect of resident’s interests/hobbies and draw up a suitable plan (group or individual) and ensure that the plan of activities is implemented. Timescale of 30/01/06 not met. The registered person must ensure there is an adequate supply of equipment and craft materials for use and staff are provided with training in recording of activities and wellbeing. The registered person must review the arrangements for the supervision of residents at meal times. The registered person must ensure all residents and their representatives are aware of the complaints procedure. The registered person must ensure a lock is provided to the shed where garden equipment is stored. The registered person must ensure: • The issues raised by the fire officer are addressed. • Doors are not propped open. If there is a need to keep them open they must be linked into the fire alarm system. • All doors must close freely into the rebate. The registered person must ensure the fridge temperature is monitored at alternatives times and if it is above the recommended level the manufacturer contacted. The registered person must ensure toilets are partitioned DS0000035597.V299833.R01.S.doc 30/07/06 12 OP15 12(1) 30/06/06 13 OP16 22 30/08/06 14 OP19 13(4) 30/06/06 15 OP19 23(4) 15/07/06 16. OP19 16(2)(j) 15/07/06 17. OP21 12(4)(a) 30/11/06 Page 28 Weatherdale Unit Version 5.2 18 19 20. OP21 OP24 OP25 13(4) 23(2)(n) 13(4) 23(2)(p) 21. OP25 23(2)(m) 22 OP26 13(3) 23 24. OP26 OP27 13(4) 18(1) 25 OP28 18(1) 26. OP29 19(1) Sch 2 from floor to ceiling. Timescale of 30/01/04 not met. The registered person must ensure the curtain rail in the bathroom is repaired. The registered person must ensure a call bell is accessible from all beds. The registered person must ensure heating controls are accessible to residents. Timescale of 30/04/04 not met. The registered person must ensure a lockable facility is available in all bedrooms for residents use. Timescale of 30/03/06 not met. The registered person must ensure: • Staff hand washing facilities are available in the sluice. • Staff remove gloves and wash their hands after dealing with incontinence or infected materials The registered person must ensure the laundry is kept locked when not in use. The registered person must ensure there is adequate numbers of suitably qualified staff on the unit at all times to meet residents needs. Timescale of 15/12/05 not met. The registered person must ensure records of NVQ training are retained on the unit for inspection purposes. The manager must ensure that all records as required in schedule 2 of the Care Homes Regulations are available on the unit for inspection. Timescale of 30/12/03 not met. If the unit wishes to make alternative arrangements a written request must be made to DS0000035597.V299833.R01.S.doc 15/07/06 30/06/06 30/11/06 30/11/06 30/06/06 30/08/06 30/07/06 30/11/06 30/08/06 Weatherdale Unit Version 5.2 Page 29 27. OP31 8(1)(a) 28. 29. OP32 OP33 10(1) 12(1) 24 30. OP35 17(2) 31. OP36 18(2) 32. OP38 23(2) 33. OP38 18(1) 34. OP38 23(4) the Commission outlining alternative arrangements. The senior managers responsible for the unit must submit to the CSCI their proposals to register a manager. Timescale of 05/02/04 not met. The registered person must ensure regular staff meeting take place. The registered person must introduce an effective quality assurance and monitoring system seeking views of resident and other stakeholders to measure the success in meeting the aims and objectives of the unit and draw up a development plan indicating outcomes for residents. Timescale of 30/04/06 not met. The registered person must ensure: • A record of all monies deposited by residents or their families is recorded. • Reimburse the comforts fund appropriately. The registered person must ensure that all staff receive formal supervision at least six times a year and records are retained in the home. Timescale of 30/01/06 not met. The registered person must ensure copies of relevant equipment servicing and checking that are held in the main home are held on the unit for inspection. The registered person must ensure there is evidence on site to indicate all the training that staff have undertaken. Timescale of 30/08/05 not met. The registered person must ensure the keypad on the entrance door is linked into the DS0000035597.V299833.R01.S.doc 30/08/06 30/07/06 30/10/06 30/06/06 30/07/06 30/07/06 30/08/06 15/07/06 Weatherdale Unit Version 5.2 Page 30 35 OP38 23(4)(e) 36 OP38 13(4) fire alarm system. Timescale of 30/08/05 not met. The registered person must 30/07/06 ensure all staff undertake at least two fire drills each year and a record is retained in the home. The registered person must 30/07/06 ensure there is at least one firstaider on each shift. 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 OP21 OP21 Good Practice Recommendations It is recommended that to offer further choice a shower room be installed on the unit. To enhance the facilities for residents it is recommended that an additional toilet be installed. Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Weatherdale Unit DS0000035597.V299833.R01.S.doc Version 5.2 Page 32 - 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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