Inspection on 17/01/06 for 1-5 New Street North

This inspection was carried out on 17th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1-5 New Street North 21/01/08

1-5 New Street North 02/04/07

1-5 New Street North 08/01/07

1-5 New Street North 01/06/06

1-5 New Street North 05/07/05

1-5 New Street North 23/03/05

1-5 New Street North 02/12/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1 - 5 New Street North West Bromwich West Midlands B71 4AQ Lead Inspector Mr Patrick Wright Unannounced Inspection 17th January 2006 11:00 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 1 - 5 New Street North Address West Bromwich West Midlands B71 4AQ 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) 0121 553 1755 0121 553 4254 enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Not Applicable Date of last inspection Monitoring Visit-10th November 2005 Unannounced inspection05th July 2005 Brief Description of the Service: 1-5 New Street is a nursing home for 8 service users who are learning disabled and require additional support due to presenting behaviour that may challenge. At the time of this inspection the occupants of the home were younger adults. The proprietor of the home is Lonsdale Midlands Ltd, and the service was first registered by Sandwell Health Authority in June 2001 The home comprises of 8 single rooms, a domestic style kitchen, 2 bathrooms, laundry, 2 lounges, an activity area, sensory room and a dining area. A lift services the first floor. Entrance to the home is via a coded door lock at the front, leading to the porch area. The home is situated on a slip road just off the main road adjacent to Dartmouth Park in West Bromwich. West Bromwich town centre is within walking distance and parking space is available at the front of the home. There is a lawned area to the front of the building and a small patio area located to the rear. The service has its own transport and regularly accesses local facilities. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted as a statutory unannounced inspection of the service. The purpose of the inspection was to assess progress and compliance in meeting the National Minimum Standards and towards addressing items identified at previous inspection visits. Inspection methods used to make judgements and obtain evidence included discussion with the newly appointed Manager and existing Deputy Manager and a number of records and documents were also examined. There are eight service users currently living at 1-5 New Street. There has been one admission of a service user since the last inspection. Service users were involved in various community activities and during the inspection a group of residents left the home to go to the theatre escorted by care staff. Service users appeared comfortable in their surroundings and the home presented a relaxed atmosphere. The previous Registered Manager has left the organisations employment since the last unannounced inspection. An Acting Manager has been appointed and is in the process of applying to be registered with the Commission for Social Care Inspection under the Care Standards Act 2000. The Acting Manager had been in post for a short time and requested that the dates for achieving the outstanding requirements be extended to allow sufficient time and planning of resources to meet them fully. Therefore not all of the outstanding requirements were assessed at this visit. These continue to be outstanding until evidence is produced at future inspections or until fully met. It is expected that improvements are made and management can evidence innovation and advancements within the home to reach minimum standards. What the service does well: Daily life at New St is reasonably flexible in terms of general routines of daily living. The communal premises are comfortable and homely. The home offers furniture and fittings, which are domestic in style and comfortable. The home has retained a `core` group of experienced staff to support the service users. The staff duty rota was examined and showed that the home continues to meet its minimum staffing requirements. Staff appear caring and supportive of service users. The home manages situations that can be described as `challenging` at times. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: 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. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 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 the following standard(s): Not applicable EVIDENCE: No standards from this section were assessed at this inspection. Progress made against requirements issued from the last inspection was reviewed. Where applicable, these will remain outstanding until fully met. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not applicable EVIDENCE: No standards from this section were assessed at this inspection. Progress made against requirements issued from the last inspection was reviewed. Where applicable, these will remain outstanding until fully met. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 16 The home does not fully enable service users to explore and take up opportunities for further education and training. Service users are enabled to become part of the local community by using local facilities. The home is working toward providing access to a range of socially and age appropriate activities in accordance with the assessed needs and individuals plan of care. Daily life at New St is reasonably flexible in terms of general routines of daily living. However, the home must evidence that daily routines promote individual choice and recognise service users rights and responsibilities. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 11 EVIDENCE: The home enables service users to continue to attend their existing, external educational facilities. These vary between each individual and the Acting Manager stated that the staff work around these placements when arranging additional events for service users. Three of the service users attend college for cookery, art sessions, etc on a part time basis. One service user also attends a day care centre. A number of service users remain at home on different weekdays. The home must ensure that structured activity/plans are implemented for all of the service users and demonstrate that other opportunities for day care and education have been explored. Records of consultation and outcomes should be available and opportunities for service users at the home to take part in valued and fulfilling activities should be in place. 1-5 New Street is in an established part of the local community, and staff and service users access local shops and amenities etc. Several staff are local to the area, and enable and support service users to use the facilities. Social inclusion is an important and essential part of the service users daily lives and staff encourage and assist service users to become part of the community as much as possible. The home has its own vehicle, (a people carrier), which is provided and maintained by the company at no extra cost to the service users. The Acting Manager told the inspector that he is hoping to implement more organised and structured days for the service users, which will include frequent community inclusion. Suitable privacy locks are fitted to service users rooms, some of which can be locked with a key from the outside preventing access. The use of keys by any service users who accept the offer is the subject of a risk assessment. Service users are not offered keys to the front door, as the home is rarely unattended, and due to suggested security risks has a coded door lock fitted. Service users have unrestricted access to the home with the exception of the kitchen, laundry, and staff room/office. Staff are aware of service users preferred term of address and this is documented in service users care files. Service users likes and dislikes continue to be identified. The Acting Manager is aware of the need for the home to demonstrate that service users privacy and dignity is respected with regards to personal care, maintaining social contacts etc and is as flexible as possible in terms of leisure and social activities, food and meal times and general routines of daily living. The Acting Manager told the inspector it is hoped that with the development of the key-worker and named nurse system this will be evidenced further in the near future. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The systems for managing service users medication are adequate, but parts of the process need updating to protect staff and service users and promote good practice. EVIDENCE: A record is maintained of current medication for each service user, and records include a photograph of each individual. Staff signatures for the homes medication policy need to be secured as an acknowledgement of its content/existence, and the specimen staff signature list needs updating. The home has a current British National Formula reference book. Medication keys are held by the nurse in charge and handed over at staff change times. Care plans are in place for service users prescribed PRN medications that detail for example, the medicine available, under what circumstances it is to be administered, and the frequency of re-administration. However these are in need of review and the Acting Manager was advised of the need to address this. None of the service users at New St self medicate and the issue of consent needs to be further explored, either with the individual or their representative, or as part of a multi disciplinary review. In addition, the nursing staff must ensure that service users attend their respective GP for the purpose of a medication review on a regular basis. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 13 The home has adopted a Monitored Dosage system. The Acting Manager was reviewing the implementation of this system at the time of this inspection. It was noted that until recently there was an excessive amount of stock medication held in the home. This should be avoided and medication should not be stored unnecessarily in the future. It is recommended that an improved system of medication stock checks be implemented. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not applicable EVIDENCE: No standards from this section were assessed at this inspection. Progress made against requirements issued from the last inspection was reviewed. Where applicable, these will remain outstanding until fully met. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The home is benefiting from maintenance work and replacement furnishings. This offers the occupants of the home a homely and presentable environment in which to live. EVIDENCE: 1-5 New St north was found to be comfortable, and clean. The home has security systems in place such as lighting, fencing and door coded locks focusing on external and internal areas. A programme of maintenance and redecoration has been implemented and this is addressing the ongoing renewal of the fabric/décor of the home. Service users rooms were not viewed during this visit. The inspector was told the home is complying with previous Environmental Health and Fire Safety Inspections. However there were issues about the system for maintaining fire safety within the home, as detailed further in this report, and some minor work remained outstanding from the Food safety inspection by the Local Authority Environmental Services department. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 The Acting Manager was unable to ascertain the number of staff that have achieved or who are working towards a National Vocational Qualification. At the time of inspection, staffing levels appeared appropriate to meet the needs of the service users. Policies with regard to recruitment and selection are available. The Acting Manager is aware of the associated practice issues required to protect service users. Evidence of completed and planned staff training was poor. Certification and training or refresher updates are required to ensure all of the staff team are appropriately trained and the service benefits from a planned staff development programme. EVIDENCE: The Acting Manager was, at the time of this inspection, unable to ascertain the number of staff that have achieved or who are working towards a National Vocational Qualification. The home must evidence it is working to meet the proposed target set by the Commission for Social Care Inspection and `Skills for Care` of at least 50 of care staff having achieved an NVQ level 2, (or equivalent). 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 17 The home operates at staffing levels of one qualified nurse and five support workers during wakeful hours, (up to six support staff when activities are planned and staff escorts are required). One qualified nurse and three support workers are on duty during the night time. These staffing levels are the minimum the home must operate at. The Registered Manager is advised of the need to monitor and adjust staffing levels, as needed, to ensure the needs of service users are being met and where necessary contact the appropriate health professional to conduct a reassessment. Records of completed training and certificated evidence available was minimal, to such an extent the current Acting Manager was unable to confirm the situation to date. The Acting Manager stated that having reviewed staff files he was unable to provide an up to date record and it would appear that staff have not been provided with updates and mandatory training as required. It was identified that an absence of training, particularly over the last six months had occurred, with the Acting Manager and Deputy Manager unable to demonstrate the current staff team are appropriately trained. Training and development of staff was examined at the inspection of 22/3/05 and a shortfall was identified at that time. It would appear that apart from NVCPI training, little action was taken to secure relevant training from the organization. The Acting Manager was advised to re-examine the records that are available in the home, and review all certification in order to produce a Training and Development plan, including a matrix of completed and planned training for all staff at the home. Subsequently, this must be submitted to CSCI and any shortfalls are prioritized. Training must be provided within a reasonable time scale. Following this inspection, a `Letter of Concern`/ Immediate requirement was sent to the Acting Manager and the organisations Responsible Individual detailing the above issue. The home operates the company recruitment procedure, which includes taking two written references prior to appointment. Information obtained includes application forms, (and a statement of health/criminal convictions) two written references, and proof of I.D. The Acting Manager is reminded to examine application forms thoroughly and explore the applicant’s employment history, particularly care related employment. Also to maintain a record of interviews conducted and discussions about any anomalies, e.g. gaps in employment history or reasons for leaving previous employment. The Acting Manager should check the authenticity of any references received. A recent photograph of each employee must be obtained and held on their respective personal file. The Acting Manager is aware that all new staff should have enhanced checks with the Criminal Records Bureau (CRB) and where applicable, to include a POVA (Protection of Vulnerable Adults) `first` check, with a written risk assessment, prior to commencement. Staff files will be examined in detail at the next inspection/monitoring visit. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 EVIDENCE: The Registered Manager has appropriate qualifications and experience for the post, and intends to undertake periodic training and development to maintain and develop his knowledge and skills. He is a Registered Nurse (Learning Disability) and is looking to commence working towards the NVQ level 4/Registered Managers Award qualification in the near future. The Acting manager must submit an application for Registration to the Commission for Social Care Inspection. Monthly visits by the company `nominated representative` under Regulation 26 of the Care Homes Regulations 2001 are being conducted, and records of these visits are being submitted to the Commission for Social Care Inspection for analysis. In addition various other audits also take place in the home, for example, estates audits. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 19 The company complaints procedure is available to all service users and their representatives, and is in suitable formats. Regular reviews of care plans and systems need to be held. Frequency and quality were discussed during this visit. Various policies and procedures are also in the process of being updated. The views of stakeholders are usually obtained verbally. The Acting Manager is advised of the need to involve the service users, staff and other stakeholders at New St in the quality assurance process, and should continue to explore ways and methods of demonstrating the quality of service is appropriate. The Acting Manager needs to produce an Annual Development plan for the home. This document should detail a system of planning, action and review for the establishment. It needs to reflect a self-monitoring tool, which includes the Regulation 26 visits and the internal audits. The actual plan will incorporate other documents such as the homes aims and objectives, (subject to review), the maintenance and redecoration plan, the staff training and development plan, and details of outcomes from the quality assurance system, including any new or reviewed policies and procedures. Lonsdale Midlands Ltd needs to consider formalising the quality assurance process for the care home. The Company holds the Investors in People Award but the home must evidence an effective system for Quality Assurance is in place based on the outcomes for service users, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. A random sample of maintenance and service records was examined. The majority of records required were available and up to date, for e.g gas safety, portable electrical testing, passenger lift servicing and water analysis testing. (It is recommended that the filing system for these records be reviewed, as there was duplication across more than one file). It was identified that Fire safety has been seriously neglected at the home. For example, evidence confirms that none of the staff, including (existing and new employees) have received any Fire safety training in 2005, (due July 2005) and have not participated in a fire drill/instruction for some considerable time. In addition, since 10/10/05 weekly alarm tests were not conducted by the home until the system was serviced on the 5/1/06. (Similarly the emergency lighting was not checked in November and December up to 5/1/06 when it was serviced). The homes Fire Risk Assessment had been updated but had not acknowledged the above issue. The document should be reviewed further. Fire extinguishers had been serviced as required. It is recommended that the home be enabled to access and use e-mail and web site facilities to assist with communication and researching current good practice and guidance. 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 3 34 2 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 X 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 2 X 2 X X 1 X 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 6 Requirement Timescale for action 30/06/06 2 YA2 14 3 YA3 14 4 YA6 15 The Statement of Purpose and Service User Guide must be kept under review and should accurately reflect the services provided. Service Users needs 30/04/06 assessments must be kept under review and revised at any time/ as part of a multi agency approach with other professionals (previous timescale of 31/10/05 partly met) The registered person must 30/04/06 demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home, and to further demonstrate it offers care based on current good practice and reflects relevant and clinical guidance (previous timescale of 30/11/05 partly met) 1) To reproduce care plans in a 30/06/06 format suitable for service users. 2) To ensure daily reports reflect goals identified in care plans. 3) To introduce effective evaluation, monitoring and reviews of service users plans DS0000004798.V279049.R01.S.doc Version 5.1 1 - 5 New Street North Page 22 5 YA8YA7 12 6 YA12 12,15,16 7 YA16YA18 12 which must be sufficiently detailed to reflect the changing needs of service users, and the objectives set. 4) Ensure that the care plans are compiled with the service user and/or their representative, and are dated/signed. (previous timescale of 30/11/05 partly met) 1) To demonstrate ways in which 30/06/06 service users are involved in the day to day running of the home and are consulted on issues affecting the service provision. 2) To further demonstrate how routines within the home are flexible and service users are enabled to exercise control 3) Staff to demonstrate how individual choices have been made and record instances when decisions have been made by others, and why. (previous timescale of 31/10/05 partly met) The home must ensure that the 30/06/06 activity plans are reviewed and staff can demonstrate that opportunities for day care and education have been explored. Records of consultation and outcomes should be available and opportunities for service users at the home to take part in valued and fulfilling activities should be in place. • The home must 30/06/06 demonstrate how daily routines and house rules promote independence, individual choice and freedom of movement, and are subject to restrictions only as agreed in the individual Plan and Contract. • Individual working records DS0000004798.V279049.R01.S.doc Version 5.1 Page 23 1 - 5 New Street North 8 YA19 12 9 YA20 13,17 10 YA23 13,18 should clearly set out residents preferred routines, likes/dislikes etc • The home must evidence and demonstrate that service users rights are respected and routines are flexible to suit the needs of individual service users. (previous timescale of 31/10/05 partly met). Supporting information/evidence must be available in each residents file for tracking information from the healthcare matrix of appointments etc (previous timescale of 30/9/05 partly met) • Service users prescribed PRN medication care plans are in need of review (By 31/03/06). • The issue of consent to medication needs to be further explored, either with the individual or their representative, or as part of a multi disciplinary review. • Nursing staff must ensure that service users attend their respective GP for the purpose of a medication review on a regular basis. • Staff signatures for the homes medication policy need to be secured as an acknowledgement of its content/existence, and the specimen staff signature list updated (by 31/3/06). Certificated evidence for all staff that have been provided with training in Adult protection is required to be held on staff files or training provided (previous timescale of 31/10/05 not met) DS0000004798.V279049.R01.S.doc 31/03/06 31/05/06 30/04/06 1 - 5 New Street North Version 5.1 Page 24 11 YA35 17,18,19 12 YA35 18 13 YA37 8,9 To ensure that induction 30/06/06 (within 6 weeks of commencement) and foundation training (within 6 months of commencement) is delivered, and is in accordance with guidance issued by the `Skills for Care` Organisation (NTO) • To ensure that relevant staff are registered on a `Learning Disability Award Framework` accredited training course. (previous timescale of 31/10/05 not met) The Acting Manager needs to 31/03/06 produce a plan for the home detailing the staff training and development programme for 2006 and must include, all training commensurate with their duties, for example, Basic Food Hygiene, National Vocational Qualifications, Infection Control, Adult Protection, First Aid, etc. This must also clearly identify programmed dates of training, for completion during the coming year, and demonstrate that each member of staff is to be provided with a minimum of at least five days paid training. `Letter of Concern` sent 18/1/06-Response required by 1/2/06. 30/04/06 • The Acting manager must submit an application for Registration to the Commission for Social Care Inspection (by 28/2/06). • The Manager must demonstrate strategies for management planning and practice, which encourages and rewards innovation, creativity, development DS0000004798.V279049.R01.S.doc Version 5.1 Page 25 • 1 - 5 New Street North and change. 14 YA39 24 The Acting Manager must produce an Annual Development plan, which is based on a systematic cycle of planning-actionreview and reflects the aims and outcome for service users (by 31/3/06) • The service must adopt and evidence an effective system for Quality Assurance based on the outcomes for service users, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. • The home must explore ways in which the service users, staff and stakeholders can be included in the homes chosen quality assurance system The Acting Manager must ensure as far as reasonably practicable the health, safety and welfare of service users and staff. 1. All staff must be provided with Fire safety training and have participated in a fire drill/instruction at the frequency required by the local Fire Safety Department (By 28/2/06). 2. Weekly alarm tests and monthly emergency lighting tests must be conducted and documented. 3. The homes Fire Risk Assessment should be DS0000004798.V279049.R01.S.doc • 30/06/06 15 YA42 12,13, 23 31/03/06 1 - 5 New Street North Version 5.1 Page 26 reviewed and updated. `Letter of Concern` sent 18/1/06Response required by 1/2/06. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA6 YA17 YA20 YA30 Good Practice Recommendations The home should begin to consider how it can implement a system of Person Centred Planning or similar, such as Essential Lifestyle Planning or Life Story books. Menus could be made available in different formats with pictorial options produced using photographs to assist service users to make a choice. It is recommended that an improved system of medication stock checks be implemented. a) The organisation should consider installing a handwashing sink in the laundry area rather than staff use the same sink for waste and mop buckets. b) A paper towel dispenser should be fitted in the laundry room. The home should continue to work toward meeting Sector Skills Workforce targets of 50 of care staff having achieved an NVQ level 2 or above. The Manager should commence working toward the NVQ IV/Registered Managers Award. It is recommended that the home be enabled to access and use e-mail and web site facilities to assist with communication and researching current good practice and guidance. The remaining minor work/recommendations that are outstanding from the last Food safety inspection by the local authorities Environmental Services department, should be completed. 5 6 7 YA32 YA37 YA41YA3 8 YA42YA24 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 1 - 5 New Street North DS0000004798.V279049.R01.S.doc Version 5.1 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. 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