Inspection on 24/10/05 for 1 Great Wood Road

This inspection was carried out on 24th October 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 43 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Great Wood Road 25/06/07

1 Great Wood Road 24/10/06

1 Great Wood Road 25/05/06

1 Great Wood Road 09/03/06

1 Great Wood Road 07/03/05

1 Great Wood Road 19/08/04

1 Great Wood Road 09/03/04

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 Great Wood Road, 1 Small Heath Birmingham West Midlands B10 9QE Lead Inspector Sue Houldey Unannounced Inspection 24th October 2005 09:30 Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 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 Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 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. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Great Wood Road, 1 Address Small Heath Birmingham West Midlands B10 9QE 0121 773 0017 0121 773 0247 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) FCH Housing & Care Ms Monica Ferguson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 7th March 2005 Brief Description of the Service: 1 Great Wood Road is a two storey home offering ground floor accommodation to service users, with the top floor being used for office space. The home caters for 4 service users with learning disabilities and diverse needs, some experiencing mobility difficulties. All service users have their own individualised bedroom. There is a car park to both the front and rear of the property. To the front is a small garden and planted area, which offers no privacy for service users. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 9am and 2.30pm. The inspector met three service users, two of whom later left for day centre placements, and the third went out on a bowling trip with staff. Due to the complex needs of service users discussion with the inspector was not possible. However, the inspector spent some time with them, and observed the way they interacted with staff, communicated and moved around the home. The inspector undertook a tour of the building and examined a range of records including two service user files. The inspector spent time with the acting manager and service manager. What the service does well: 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. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 6 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 Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 7 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): 3 Service users cultural needs are well met by this home. However, the home is failing to ensure the religious needs of service users are fully met. EVIDENCE: The home offers good support to meeting service users individual cultural needs. This includes the provision of a range of diets and separate facilities for the storage and preparation of diets including Halal food. Examination of the care plans and daily records of two service users indicated that the home is failing to meet the religious needs of one service users who enjoys attending church. The last such visit was documented as taking place in May 2005 Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 8 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): 6, 7,9 Service users are well supported to make choices and communicate their decisions to staff. Care planning, recording and risk management is not robust enough to ensure that service users current needs are known, acted upon and their well-being safeguarded. EVIDENCE: Service users in this home have complex needs and are reliant upon staff to interpret their none verbal communication, to ensure their wishes are met. Some service users have communication aids, such as ‘Big Mac’ which staff were seen to make available to aid communication. The inspector observed staff assisting service users to make decisions, and respected the decisions, which had been made. Service users in this home are not able to manage their own finances. The home assists service users to manage their finances, and hold bankbooks, and finance ledgers for each service user. The accounting system demonstrated that these monies are well managed on behalf of service users. The home are developing guidance for staff to assist in deciding which purchases should be made by service users and which should be paid for from petty cash, this will afford service users greater protection from abuse of their finances. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 9 Two service users care plans and daily records were examined. The plans dated 2002 are currently being reviewed to ensure that the home is providing service users with the support they need and require. The inspector was advised that risk assessments are also being reviewed. Daily diaries are maintained which ensure that information pertinent to the service user is effectively communicated between the staff team. The standard of writing in this diary, was in some instances poor. The acting manager was asked by the inspector to read one entry and was unable to decipher all of the writing. This may place service users at potential risk, and prevents effective communication, and detailed review of needs. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 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, 14, 16, 17 Service users are supported to participate in a range of appropriate activities and leisure pursuits in the home and within the wider community. Mealtime routines promote the dignity and independence of service users. The planning of menus does not ensure service users nutritional needs are fully met, although their cultural dietary needs are catered for. EVIDENCE: Some service users attend day centres for all or some part of the week. The inspector observed service users getting ready to go out to these placements, and they were clearly looking forward to going. On the day of the inspection one centre was closed. One service user remained at home until staff took her out bowling, an activity she is reported to enjoy. Examination of two daily diaries and financial records indicate that service users participate in a number of leisure activities within the community. Within the home there is a range of equipment, which service users enjoy using, both within communal areas and individual bedrooms. On the day of the inspection service users enjoyed listening to music, used sensory equipment, and played electronic keyboards, prior to going out to individual activities. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 11 When the inspector arrived at the home one service user had already left for their day centre. Two service users were moving around the home, and were offered refreshments. One service user was having a lie in, and was later assisted with personal care and breakfast. The daily routines clearly promote the independence of service users who are afforded freedom of movement and choice about routines. No staff were interviewed at this inspection, but the inspector observed how they worked with service users. Staff were seen to talk to service users, and involve them in conversations. When service users chose to be alone in their rooms this was respected. The home has a complex menu displayed. The range of choices appear to be limited and service users files indicated that individual preferences were poorly documented. The acting manager advised the inspector that these were currently under review. Discussion with a dietician may assist the home in developing menus, which make catering manageable for staff, and ensure that individual service users preferences are catered for. Staff were seen to offer discreet and appropriate support to one service user during breakfast. The practice observed was relaxed and unrushed and promoted the independence and dignity of the service user. The home has appropriate facilities for storage and preparation of Halal diets. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 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): 18, 19, 20 Service users receive appropriate levels of support with personal care, and their independence and dignity is promoted. Systems within the home do not offer sufficient safeguards in relation to health promotion or medication management, which places service users at potential risk EVIDENCE: Service users were seen to be well dressed with appropriate attention having been given to hair and nail care. Service users clothing reflected their age and personal taste. One service user had declined to be shaved and this was respected. Daily diaries contained evidence that service users may get up and go to bed when they choose. Service users have key workers, who are currently assisting the updating of care plans. Service users have a choice of staff who work with them, both male and female and may be assisted by staff from the same cultural background. The home maintains health care records. Two such records were examined, and found to contain insufficient detail about follow up action (such as blood tests). The acting manager explained these had been followed up but staff had failed to record appropriately. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 13 One service user has periods when he chooses not to eat well, the home do not currently monitor his weight, so have no way of telling if there is any significant loss, or additional support required. Poor practice in the monitoring and recording of health matters could lead to service users failing to receive the support they require to stay healthy. Examination of accident and incidents records indicated that one service user has experienced redness, which the home feel may be due to the continence pads not being appropriate. The home took action to use a proprietary brand of cream which they purchased from a chemist to treat this condition. In order not to place this service user at further risk of developing pressure areas, or experiencing discomfort the home should seek professional assistance in assessing these concerns. Service users medication is stored in individual cabinets within bedrooms; this reduces the potential for errors and ensures service users are afforded the privacy of being offered and taking medication in private. Three service users medication cabinets were audited. The home safeguards service users by ensuring copies of prescriptions are checked against medication coming into the home, and records are retained. Overall medication practice is good. The documentation of stock checks for those items which are not blister packed or which are PRN (as required), would offer service users further safeguards. Better attention to the cleaning of cabinets by staff administering medication may prevent further staining of carpets in individual bedrooms Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 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): 22,23 The home has not provided staff with the required training in adult protection matters. Together with poor recording of protection issues this places service users at significant potential risk. EVIDENCE: Policies and procedures relating to complaints and protection were not examined at this inspection. However it was noted that the home now has a log to record complaints which will ensure that service users concerns are recorded and acted upon. The inspector was advised that not all staff have received adult protection training. It was noted that some unexplained injuries or bruising had not been appropriately documented. These issues must be addressed to ensure service users are adequately protected. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 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, 25, 26, 27, 28, 29 The homes refurbishment has improved the living environment for service users. Further work is required to improve the homely nature of the environment and ensure service users are safe. EVIDENCE: The home has been extensively refurbished. Service users were accommodated in a nearby hotel, whilst some of this work was undertaken, this meant that they remained close to family and were able to continue to attend their day centre placements. The bathroom and shower room have been completely re-fitted. The level access shower and bath with mechanical seat, ensure that service users are able to use either facility as they choose. Grab rails by the toilet in the shower room had not been properly fixed and the coating was peeling off. This could put service users at risk of an accident, and prevents the area being maintained to appropriate standards of hygiene. During the inspection work continued on re-painting the lounge, dining area and corridors. The choice of more relaxing, homely colours, and purchase of new sofas and chairs has enhanced the appearance of the home and provided service users with a more relaxing environment. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 16 The acting manager confirmed that it was hoped to re-decorate at least two bedrooms where the decoration is becoming worn, and she is working towards proving all of the furniture required in standard 26. One service user has a ‘hospital bed’, which detracts from the appearance of her room, which is otherwise individual to her personality and culture. In addition, the inspector questioned the safety of the bed sides (sometimes referred to as cot rails), which had no safety cover, which would prevent limbs becoming caught in them. The manager was not able to say whether the bed sides were safe without covers, or whether the service user may be at risk of injury, as there is no risk assessment. The carpets throughout the home have become stained and detract from the appearance of the environment. Individual bedrooms reflected the personality and individual preferences of service users. Lighting levels in these rooms were poor, being from a central bulb only. In particular the lighting levels by the individual medication cabinets in bedrooms, may present a risk to service users, as errors may occur in the recording or administration of medication. To the rear of the home, a fence has been fitted which has improved the security of this area. To the front of the home, further development of the garden is required to ensure service users are safe and afforded privacy. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 17 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): 33, 34, 36 The homes recruitment policies work towards protecting service users from potential abuse. Development of training and supervision levels will offer further safeguards. EVIDENCE: The home currently has no staff vacancies. The rota shows that three support staff are employed on each daytime shift ensuring that staff are available to meet individual service users needs. These staffing levels ensure that service users are offered opportunities to go out during the day and evening should they wish. The staff team reflects the cultural and gender composition of the service users, ensuring service users have a choice of staff with whom they can interact or receive support. Regular staff meetings are held at which a range of issues are discussed. This ensures that changes in policy, well being of service users or other matters are discussed and acted upon by the team promptly. Files for two new staff at the home indicated that the providers recruitment procedures ensures that service users are protected from potential abuse. This is further demonstrated by a comprehensive induction and training programme, and the probationary period for all staff which is reviewed periodically. Training in adult protection and basic food hygiene for all staff will further enhance service users protection. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 18 The inspector examined the supervision records for two staff. These indicated that the level of recording was not detailed enough and the frequency should be increased to ensure that service users are supported by a staff team who are sufficiently skilled and able. In particular, where staff are noted to be performing below an acceptable standard this supervision should be more frequent to ensure service users are safeguarded. Currently the acting manager works 9am to 4.30pm, this does not allow oversight of all aspects of the running of the home. In order to ensure that the support offered to service users is appropriate and meets their needs, and that staff performance is assessed the manager should attend the home at other times. Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 19 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, 41, 42 Inadequate recording and risk management in some areas are currently compromising the health and safety of service users. EVIDENCE: The home has an acting manager, who was previously deputy manager of the home. It was clear that the manager has been proactive in addressing a number of requirements from the last inspection, however the home has a considerable way to go to fully meet the standards required. The CSCI has received an application to register this manager, but is awaiting receipt of a completed CRB request to process this application. The inspector raised concerns that the manager appeared to be failing to address a number of key areas, and in part this must be attributed to the 43 requirements that were made or outstanding at the last inspection, and the managers relatively new appointment to this position. In order to facilitate improvement the manager has undertaken to consider how she can better delegate some of the development work to staff to encourage participation and ownership by the staff team Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 20 The home has an accident/incident book, which does not comply with current data protection legislation. and does not afford service users privacy. Examination of these records highlighted some concerns about the recording of unexplained injuries, which should be documented with a body chart to afford service users greater protection. In addition, the management of continence and pressure area relief was questioned and the home should seek professional support in this area to ensure service users are sufficiently safeguarded. A number of health and safety records were examined. The fire records were found to be complete with the exception of weekly fire alarm tests. The home has a gas safety certificate and an electrical wiring certificate. Portable appliance checks were reported to have been completed but no record maintained. The manager reported that not all manual handling assessments had been completed. Improvement in recording and documentation of health and safety matters will further safeguard service users from potential risk The night waking staff document fridge and freezer temperatures daily. The records do not indicate the optimum temperatures, which should be achieved to safeguard service users from potential harm. Nor do they document what action is taken by staff to remedy temperatures which are detected outside of an acceptable range. One of the fire doors in the home is failing to close completely following refurbishment, this places service users at potential risk in the event of a fire. The newly fitted shower was tested and the temperature found to be so high that the inspector and manager could not hold their hands under the water. This places service users at a risk of being scalded. The manager took immediate action to notify the maintenance department of the providers, and warning notices were placed around this area. The inspector was advised that this was to be remedied on the day after the inspection Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 21 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 2 2 2 X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 2 2 3 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Great Wood Road, 1 Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 2 X X 2 2 2 X DS0000016922.V260610.R02.S.doc Version 5.0 Page 22 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 4(1) c Schedule 1 Requirement Timescale for action 21/12/05 2 YA1 17(2) Schedule 4 The home must further develop the statement of purpose to include: (a) Name and address of registered provider and any registered manager (b) The arrangement for dealing with complaints to include details of CSCI (c) The number and size of rooms in the home (Previous timescale 1/05/05 – not examined at this inspection) The home requires a service user 21/12/05 guide to include: (a) summary of statement of purpose (b) Terms and conditions in respect of accommodation to be provided, including amount and method of payment (c) Standard form of contract (d) Most recent inspection report (e) Summary of complaints (f) Details of CSCI DS0000016922.V260610.R02.S.doc Version 5.0 Great Wood Road, 1 Page 23 3 YA2 4 4 YA3 12(4) 5 YA6 17(1) a Schedule 3 6 YA6 17(1) Schedule 3 (Previous timescale 1/05/05 – not examined at this inspection) The home requires an admissions policy, including emergency admissions (Previous timescale 1/05/05 – not examined at this inspection The home must ensure that the expressed wishes of service users to follow their religion are acknowledged and addressed The home must develop service user plans to include: (a) Detailed up to date care plans which are subject to review. These must include the goals and aspirations of service users (b) Activity plans and monitoring of such (Previous timescale 1/06/05 – extended ) Daily diaries require more detail and must include activities/opportunities, which have been offered to service users. These records must contain details of care offered, care received ad response to care. (Previous timescale 1/06/05 – extended) The home must ensure that records maintained are legible There must be guidance in place, in sufficient detail to assist the staff to know which purchases can be made from personal allowances and which purchases are the responsibility of the provider (Previous timescale 1/06/05 – extended ) 21/12/05 28/10/05 21/12/05 21/11/05 7 8 YA6YA41 YA7 17 12(1) a 28/10/05 28/10/05 Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 24 9 YA9 13(4) Further development of risk assessments is required. The home must ensure: (a) (b) Existing controls are cross referenced to further action required Read and sign sheets should be inserted, indicating that staff have read and agreed to follow risk assessments Risk assessments must be cross referenced to existing policy and procedures Risk assessments must be cross referenced to care plans, again with read and sign sheets, indicating staff will bring to the attention of the management of the home, any concerns, or changes to these Risk assessments must contain the date of implementation and review The review of risk assessments must include a rationale for it’s continuation in it’s present form 21/12/05 (c) (d) (e) (f) 10 YA17 16(2) I 11 YA17 12(3) (Previous timescale 1/06/05 – extended) The home must ensure the diet 21/12/05 provided to service users is varied and nutritious. The home is advised to seek support from a dietician (Previous timescale 1/05/05 – extended) Service users must be involved 21/12/05 wherever possible in determining meals and alternative choices DS0000016922.V260610.R02.S.doc Version 5.0 Page 25 Great Wood Road, 1 12 YA19 14(2) & 15 13 YA19 14(2) & 15 14 15 YA19 YA20 17(1) Schedule 3 13(2) (Previous timescale 1/05/05 – extended) The home must ensure that where there are concerns about: nutritional intake of service users, that appropriate steps are taken to monitor weight, and address any concerns to relevant professionals for advice an assistance The home must ensure that where there are concerns about pressure area care or continence management, that these are referred to appropriate professional for advice an assistance The home must ensure that health checks and follow up action are fully documented The home must ensure that systems for the safe handling, administration and recording of medication are in place. These must include: (a) Stock checks on all none blister packed or PRN (as required) medication Medication no longer used is subject to review with the GP or consultant. Improvement in the handling and hygiene of medication and cabinets 28/10/05 28/10/05 28/10/05 21/11/05 (b) (c) 16 YA22 17(20) Sch 4 The homes complaints procedure must be amended to ensure service users are informed in writing/suitable format of the complaints procedure including: (a) (b) (c) The manner in which complaints should be made A commitment on the 21/12/05 Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 26 (d) (e) (f) part of the home that all complaints will be taken seriously Assurance that no service user will be victimised for making a complaint To whom the complaint should be made in the first instance Further steps if remaining dissatisfied and information of the role of CSCI in dealing with complaints (g) The procedure should be available to service users families (Previous timescale 1/05/05 – not examined at this inspection) The home must have a written policy and procedure on physical intervention, which should be in line with codes of professional practice recognised by relevant professionals Physical intervention must be written in the care plan with a description and reason for use, and on whose authority. It must be subject to frequent documented review (Previous timescale 1/05/05 – not examined at this inspection) The home must ensure that where unexplained injuries or bruising is seen that this is fully documented using a body chart. This must then be referred via the adult protection procedures and notified to CSCI The garden area offers little privacy for service users and DS0000016922.V260610.R02.S.doc 17 YA23 13(7) & (8) 21/12/05 18 YA23YA41 13(6) & 37 28/10/05 19 YA24 23(2) a 31/03/06 Great Wood Road, 1 Version 5.0 Page 27 appropriate screening or other means must be used to address this. (Previous timescale 1/06/05 – extended) Steps must be taken to address the uneven paving in the garden, which present a trip hazard (Previous timescale 1/06/05 – extended) Carpets throughout the home must be cleaned or replaced if cleaning proves ineffective in removing stains The home must review the lighting level in bedrooms, to ensure sufficient levels of lighting are available for staff administering medication The two bedrooms identified need to be redecorated (Previous timescale 1/06/05 – extended) Service users bedrooms must be provided with furniture as detailed in standard 26. Any divergence from this standard should be fully documented in individual files and subject to periodic review (Previous timescale 1/06/05 – not examined at this inspection) Blinds must be fitted to 28/10/05 bathrooms and shower rooms to ensure service users are afforded privacy The grab rails situated around 21/11/05 the toilet in the shower room must be recoated or replaced. The home must ensure these are appropriately fixed to prevent the risk of accidents The home must replace the 21/01/06 hospital bed, with a bed which is DS0000016922.V260610.R02.S.doc Version 5.0 Page 28 20 YA24 23(2) o 31/03/06 21 YA24 23(2) d 21/01/06 22 YA24 23(2) p 21/11/05 23 YA25 23(2) d 21/01/06 24 YA26 23(2) c 21/01/06 25 YA27 16(2) c 26 YA29YA30 23(2) c 27 YA29 16(2) c & 23(2) c Great Wood Road, 1 28 YA29 13(4) suitable for the needs of the service users, and is as domestic in nature as possible The home must ensure that the bed rails used do not present a risk to the service user. The home must supply CSCI of evidence of the outcome of this investigation The home must ensure that staff are confident in the content and provision of policies and procedures in respect of (a) (b) (c) Sexuality Adult Protection Their role in facilitating complaints for service users 28/10/05 29 YA32 18(1) c 21/12/05 30 YA35 18(1) a & c (Previous timescale 1/05/05 – not examined at this inspection) Training must be provided to all care staff to include: (a) (b) Hygiene and food handling Adult Protection 21/01/06 31 YA36 18(2) (Previous timescale 1/06/05 – extended) The manager must ensure that staff receive regular supervision, at a minimum of six times per year (Previous timescale 1/06/05 – extended) The manager should work across all shifts in the home to ensure sufficient management oversight The manager must submit a CRB form to CSCI in order for the application for registration of the manager to be processed. The home must ensure that accident records are compliant DS0000016922.V260610.R02.S.doc 21/11/05 32 33 YA36 YA37 18(1) 3(3) Reg.Regs 17(2) Schedule 21/12/15 21/11/05 34 YA41 28/10/05 Great Wood Road, 1 Version 5.0 Page 29 4 with the Data Protection Act 1998 (Previous timescale 1/05/05 – extended) The hot water to the shower 28/10/05 outlet must be regulated to prevent the risk of scalding The home must carry out manual 21/11/05 handling assessment, planning, monitoring and review for all service users (Previous timescale 1/05/05 – extended) The home requires COSSH risk assessments and data sheets to be in place 35 36 YA42 YA42 13(4) 13(5) 37 YA42 13(4) 21/01/06 38 39 YA42 YA42 23(4) 23(4) 40 YA42 16(2) j (Previous timescale 1/05/05 – not examined at this inspection) The home must ensure that fire 21/11/05 doors close fully onto their rebate The home must ensure that fire 28/10/05 alarms are checked weekly and a record is maintained of these checks The home must ensure that 28/10/05 fridge and freezer temperature checks include: (a) The acceptable range for temperatures (b) Action taken to address variances from the acceptable range RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA39 Good Practice Recommendations It is recommended that the manager explores how task DS0000016922.V260610.R02.S.doc Version 5.0 Page 30 Great Wood Road, 1 can be delegated to staff to further facilitate compliance with requirement and participation and understanding of the staff team Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Birmingham Office Ladywood House 45–56 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 Great Wood Road, 1 DS0000016922.V260610.R02.S.doc Version 5.0 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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