Inspection on 01/08/05 for Westfield Road (1)

This inspection was carried out on 1st August 2005.

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

Westfield Road (1) 15/12/08

Westfield Road (1) 19/12/06

Westfield Road (1) 16/01/06

Westfield Road (1) 02/02/05

Westfield Road (1) 09/11/04

Westfield Road (1) 01/03/04

Similar services:

Flint House

The Cotswold Home

Fairways

Treloar College

Rush Court

The Maypole Nursing Centre

Fir Tree Lodge

Chilmington House

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

CARE HOME ADULTS 18-65 Westfield Road (1) 1 Westfield Road Bletchley Milton Keynes Bucks. MK2 2RR Lead Inspector Maureen Richards Unannounced 1 August 2005 at 9.15am st 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westfield Road (1) Address 1 Westfield Road, Bletchley, Milton Keynes, Bucks, MK2 2RR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01908 366168 The Disabilites Trust Care Home 3 Category(ies) of Physical Disability (PD) (3) registration, with number of places Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 This home is registered for 3 people with a physical disability. Date of last inspection 8th February 2005 Brief Description of the Service: Westfield Road is a care home for three people with a physical disability. The aim of the home is to provide rehabilitation for people with brain injury into more independent living. The home is owned by the Brain Injury Rehabilitation Trust. The day to day support and external management of the home is provided by Thomas Edward Mitton House, which is based in Milton Keynes. The home consists of a two-storey building. All of the bedrooms are single, and one of the bedrooms has an en -suite shower. The home is situated in Bletchley, close to local shops, leisure facilities and other amenities. It is easily accessible for public transport. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Westfield Road took place over three and three quarter hours on the morning of Monday 1st August 2005. The inspection consisted of an introduction and brief discussions with the service users, a tour of the communal areas of the building, examining records, discussions with the house leader and support staff on duty. The aim of the inspection was to establish progress with requirements from the previous inspection and to assess some of the key standards during this inspection. Some requirements from the previous inspection have not been fully complied with and have been repeated at this inspection. What the service does well: What has improved since the last inspection? What they could do better: The manager must be actively involved in the decision to admit service users to the home. Staff must be informed and made aware of prospective service users needs prior to admission to ensure that staff feel able to meet their needs. The admission documentation must be updated to reflect admission to the home. Up to date risk assessments, guidelines and rehab plans must be put in place at the point of admission. All staff should be aware to follow the correct procedure for the recording of information. Service user files should be reorganised and made more accessible. Risk assessments must be specific and detailed as to how risks should be managed. Risk assessments must be kept updated as service users needs and management of situations change. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 6 All staff responsible for administering medication must be assessed and deemed competent to administer medication. Written confirmation of this must be maintained on staff files. Written guidelines must be obtained on the use of all as prescribed medication. The local medication policy must specifically outline the procedure for disposal of medication. The local policy on dealing with a death should clearly outline the procedure for dealing with an unexpected death. All staff files must be maintained at the home at all times. All staff must have all the required safe working practice training and training records should be reorganised, made accessible and kept updated to reflect what training has actually taken place. The house leader must attend supervision training to ensure that she is confident in supervising care staff. There has been a change of manager and a change in the staff structure with a house leader in charge of the day-to-day management of the home and two new care staff have been appointed since the previous announced inspection. It is important that these changes are effectively managed and monitored to ensure that the home continues to meet standards and address requirements. 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. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The process of admitting service users to the home is unsafe and potentially puts staff and service users at risk. EVIDENCE: New admissions to the home are generally admitted to Thomas Edward Mitton house and transferred from there to Westfield Road. The decision to admit to the home is made at a review meeting. Service users are made aware of this decision and given the opportunity to visit and meet other service users and staff. Staff at the home do not carry out their own assessment of prospective service users and a recent admission to the home took place whilst the manager and house leader were on leave. The house leader confirmed that she is not involved in the decision to admit and was not clear whether the manager is. The documentation, which includes the date of admission, is for admission to Thomas Edward Mitton House and not the date of admission to Westfield Road. Service users admitted to Thomas Edward Mitton house undergo a twelveweek assessment process and care plans are put in place following this assessment. This service user did not have a plan of care in place as it was felt he was still under the twelve-week assessment, however the date of admission to Thomas Edward Mitton house indicates that it was seventeen weeks since his initial admission. This individual was transferred to Westfield Road without clear guidelines for staff on how to support this individual and without up to date risk assessments in place. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 9 The home currently has a service user vacancy. The house leader confirmed that she had been told that there is somebody identified to move into that vacancy but that she had not been made aware who this was. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 Rehab plans are not put in place following the assessment period to provide staff with the information they need to meet service users needs in a safe and consistent way. Risk assessments lack specific detail on the management of risk and are not kept updated and reviewed as service user needs change, which could compromise the safety of service users and staff. EVIDENCE: At the time of this inspection two service users were living at the home. Both service users plans were seen. Both service user plans included a photograph and a personal details information sheet, which was completed on admission to Thomas Edward Mitton house but not updated to reflect admission to Westfield Road. As outlined in standard 2, one service user did not have a rehab plan in place and had two sets of guidelines, one from the speech and language therapist and one from the occupational therapist. The other service user had a rehab plan in place which was updated in March 2005. The rehab plan did not include a specific review date. The manager confirmed that rehab plans are reviewed at rehab meetings and updated and Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 11 reviewed following those reviews if required. It was difficult to find evidence of this within service users files. Service user plans included progress notes. One service user had no entry in their progress notes since the 18th July. Staff also record on an individual daily record and there appears to be some confusion as to when the progress notes should be completed. The progress notes did not include the name of the service user and some entries were not dated or signed. The house manager confirmed that the daily recording sheets are used for daily information and updates. The progess notes are used to record meetings, specific one-off situations and telephone calls etc. The house manager should ensure that this is reinforced to support staff responsible for recording this information. Service user plans were disorganised, contained duplication of some information and it was difficult to find up to date and relevant information. Service user plans included a series of risk assessments. Risk assessments are completed by the clinical psychologist and are supposed to be updated and reviewed at the rehab meetings. The risk assessments on one service user’s files were not updated to reflect his admission to Westfield Road and one risk assessment indicated that this person continued to need constant observation, which in fact was not the case. The risk assessments for the other service user had not been updated to reflect the level of supervision required when out of the home or when carrying out specific tasks. During the inspection one service user went out unsupervised, which he is allowed to do, but there was confusion as to how long they should wait before the police should be notified. The risk assessments lacked specific detail on how staff manage risks. One risk assessment indicated that the individual required supervision with medication but did not outline what level of supervision was required. One risk assessment identified that there was a potential for violence as a reaction to frustration but did not outline how staff manage this frustration to ensure a consistent approach and prevent a violent situation arising. One risk assessment indicated that there was a risk of seizures and the action was that this individual has a history of “drop fits”. There was no indication of what a “drop fit” was and no guidelines for staff on how this should be managed. Staff on duty were not aware that there was a risk of seizures and were unable to explain what would be considered a “drop fit” and therefore unable to safely manage such a situation. Some risk assessments made reference to the introduction of guidelines as required however there were no specific guidelines within the service user file to refer to. In one file there was a handwritten note to record negative thoughts and comments. This did not include the service users name or date. There was no reference in the service user’s plan as to why this was being recorded and what action should be taken in response to the negative thoughts. Some risk assessments were photocopied and in some the risk ratings was crossed out and changed with no indication as to why the rating changed. The Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 12 risk assessments did not indicate a date of review or evidence of service user involvement. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the above standards were assessed at this inspection. All of the above standards were met at the previous announced inspection. The key standards in this section will be assessed at the next announced inspection. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 & 21 Improvements are necessary to medication practices to safeguard service users. The dealing with death policy does not include the procedure for dealing with an unexpected death, which could result in a sudden death of a service user not being managed appropriately. EVIDENCE: None of the current service user group are self- medicating. The decision to self medicate is agreed at the rehab meetings with the relevant professionals involved. The medication administration record indicates that all medication administered is signed for. In some medication administration records the home had used the O code to indicate “other reason why this medication was not administered,” but there was no explanation given as to what the O code meant. One service user is on prescribed, as required medication, but there are no guidelines in place as to why or up until what time of the night this medication can be administered. Guidelines must be obtained from the prescribing GP to support this. The home keeps a separate record of all medication received and disposed of back to the pharmacy. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 15 Staff hand write interim prescriptions on the medication administration record. It is advised, in line with the new pharmaceutical guidelines, that two staff check and sign to confirm any interim prescriptions. The new staff member confirmed that she was assessed and went through the medication procedure prior to being involved in administering medication. However there is no written evidence on this staff members personal file to support this. Some staff have completed the medication administration course run by Milton Keynes College and the new staff member confirmed she is currently on this course. The home has a local policy on the administration of medication. The procedure makes reference to dealing with spoilt medication but does not clearly outline the procedure for disposal of medication to the pharmacy. The policy must be updated to include this. Service user plans include the service users wishes in the event of death. This is signed by the service user and countersigned by a staff member. The home has a local policy and an organisational policy on dealing with a death. The local policy was seen. The policy does not specifically outline the procedure to be followed by staff in the event of an unexpected death and the manager should include this as an appendix to this policy. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home has a complaints procedure in place, which is accessible to service users and encourages them to make comments about the service they receive. Policies, procedures and training are in place, which ensures the protection of service users. EVIDENCE: The home has a complaints procedure in place, which indicates that complaints will be responded to within 28 days. At the previous announced inspection the pre inspection questionnaire indicated that there had been two formal complaints. A record of the complaint and outcome of the complaint was not filed at the home. The unit manager advised in the action plan that there had been in fact one complaint during the period under review. A copy of that complaint and outcome was sent to the Commission and a copy was found to be at the home at this inspection. The house leader confirmed that there have been no complaints since the last inspection. The home has a copy of the organisation’s policy on reporting bad practice and adult abuse. This policy was reviewed in 2003 but did not indicate a future date of review. At the announced inspection the manager had developed a local adult protection policy, which was not in line with adult protection interagency procedures. At this inspection the local policy was no longer in place and the organisation’s policy is now used as guidance for staff. There have been no reported abuse allegations since the previous announced inspection. A previous adult protection complaint was found to be investigated and dealt with appropriately, however correspondence relating to that investigation is not maintained on the staff file kept at the home. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 17 New staff to the home are expected to read and understand the adult protection policy and confirmation of this is outlined on staff induction. Staff have up to date training on adult protection. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The home is welcoming, well maintained, bright, and clean and provides a safe and homely environment for service users. EVIDENCE: The home is situated on a busy road. It is unobtrusive in its surroundings and is in keeping with the local community. The home is close to local shops and is accessible to Milton Keynes. The home is nicely decorated, bright, homely and welcoming. Some areas of the home have been decorated since the previous inspection and other areas are scheduled to be decorated, refurbished and updated during this financial year. Furnishing and fittings are domestic in appearance and are maintained in good condition. All areas of the home are accessible to service users. There is a rear patio area with hanging baskets and plants. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35 & 36 Some staff files are not maintained at the home and some files do not contain all the relevant information as outlined in schedule 4 (6). It is difficult to establish if safe recruitment practices are being followed for new staff which potentially puts service users at risk. Not all staff have up to date safe working practice training which compromises the health and safety of service users. The house leader has not received supervision training, which potentially could mean that care staff are not being properly supervised. EVIDENCE: The home has had two new staff appointed since the previous announced inspection. Both of the files for these staff were requested but were not available. The house leader confirmed that both of these individuals have requested to go on the bank for other homes and as a result their files had been removed from the home and taken to Thomas Edward Mitton house so that the relevant information could be photocopied. This had happened a couple of weeks previously but the files had not been returned. This is unacceptable and the organisation is reminded that Schedule 2 information must be available at the home at all times. A requirement was made at the previous announced inspection for Schedule 2 and 4 (6) information to be made available at the home for all staff working at Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 20 the home. This has not been complied with. Schedule 4(6) outlines that correspondence, reports, records of disciplinary and any other records in relation to staff employment be maintained on staff files. This is not the case in relation to the previous adult protection investigation as outlined under standard 23. The training records seen indicate that some safe working practice in fire safety, COSHH and moving and handling is overdue for some staff. The food hygiene training was scheduled to take place on the afternoon of this inspection. The house leader confirmed that the safe working practice training was scheduled but was cancelled and those individuals are now being nominated to attend the next training course although no date had yet been agreed. The training records were disorganised and not updated to accurately reflect what training had taken place. New staff complete an in house induction and the induction pack for one of the new staff was seen. Some areas within the induction had not been signed off. One of the care staff has an NVQ. The house leader is scheduled to go on NVQ training but no date has yet been agreed. The house leader confirmed that she receives regular supervision from the manager and she in turn supervises the care staff on a monthly basis. This was not confirmed by staff and supervision records were not requested at this inspection. A requirement was made at the previous announced inspection that the house leader must attend supervision training. The house leader confirmed that this has not happened and no date is scheduled for this to take place. The action plan from the previous announced inspection indicated that this would be complied with by 30.04 05 which has not happened. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 There are a number of requirements not complied with from the previous announced inspection which compromises the health and safety of service users. EVIDENCE: The manager has applied to the Commission to become the registered manager of five services. The home has a house leader who is responsible for the day-to-day running of the service with support and guidance from the manager. The house leader confirmed she is still developing in this role. The house leader is included on the rota and administration time is made available as and when she can fit it in. The manager is based at Thomas Edward Mitton house and is accessible to the home as and when required and in a monitoring role. She arrived at the home during the inspection to support staff to deal with two incidents but left once these were felt to be in hand. At the previous announced inspection the manager confirmed she was undertaking her NVQ 4. It was not established at this inspection whether this has now been completed. There are a number of requirements outstanding from the previous announced inspection, which ultimately are the responsibility of the registered manager Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 22 and not the house leader. The organisation and manager must address these and ensure that effective systems of monitoring are in place to ensure that requirements are being complied with. Failure to do this will lead to these matters being referred to the Commission’s Legal Services Department for consideration of enforcement action. There have been staff changes and a change in the management structure within this service. It is important that those changes are effectively managed and monitored so that new staff feel confident, supported and clear of their roles. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x x 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westfield Road (1) Score x x 2 2 Standard No 37 38 39 40 41 42 43 Score 2 x x x x x x H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 14 Requirement The manager must ensure that she is actively involved in the decision to admit service users to the home. The manager must ensure that staff are kept informed of who is to be admitted prior to admission to ensure that staff feel able to meet the service users needs. The manager must ensure that the admission documentation is updated to reflect admisson to the home. (Previous timescale of 31/03/05 not met) The manager must ensure that relevant rehab plans,guidelines and up to date risk assessments are in place on admission. ( previous timescale of 31/03/05 not met) The manager must ensure that risk assessments are specific and detailed as to how risks should be managed. Risk assessments must be kept updated as service users needs and managment of situations change.( previous timescale of 31/03/05 not met) Written guidelines must be obtained from the prescriber on the use of all as required Timescale for action 10th September 2005 30th August 2005 2. 2 13 3. 2 14 30th August 2005. 4. 2 14 & 15 10th September 2005. 5. 9 13 10th September 2005. 6. 20 13 30th September 2005. Page 25 Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 medications. 7. 20 13 The manager must ensure that all staff responsbile for administering medication have been assessed and are deemed competent to administer medication.Written evidence must be on the staff members file to support this. The local medication policy must specifically outline the procedure for disposal of medication. The manager must ensure that explanations are given on the codes used as to why medication was not adminstered. The manager must ensure that all schedule 2 and 4 (6) information is maintained at the home at all times for all staff who work at the home. ( Previous timescale of 31/03/05 not met) The manager must ensure that all staff have up to date safe working practice training and training records must be kept updated to accurately reflect what training has taken place. The house leader must attend supervision training. (previous timescale of 40/04/05 not met) 30th August 2005. 8. 9. 20 20 13 13 30th September 2005. 30th August 2005. 30th August 2005. 10. 34 19 11. 35 18 30th September 2005. 12. 13. 36 18 30th September 2005. 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 6 & 17 20 Good Practice Recommendations Service user files should be reorgansied and made more accessible. The local death policy should include the procedure for dealing with an unexpected death. H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 26 Westfield Road (1) 3. 4. 35 6 & 17 Staff training files should be reorgansied, kept updated and made more accessible. The manager should ensure that staff are clear as to where and how information should be recorded in service users files and entries should be dated and signed. Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 27 Commission for Social Care Inspection Cambridge House 8 Bell Business Park Smeaton Close, Aylesbury Bucks. HP19 8JR 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 Westfield Road (1) H53_H02_S15079_Westfield Road_V239773_UI 01 08 05_Stage 4_MR_ces.doc Version 1.40 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!