Inspection on 09/03/06 for 1 Great Wood Road

This inspection was carried out on 9th March 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 30 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 24/10/05

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 Alison Stone Unannounced Inspection 09 March 2006 10:30 Great Wood Road, 1 DS0000016922.V280946.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 Great Wood Road, 1 DS0000016922.V280946.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. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 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.V280946.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 24th October 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.V280946.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day. The inspector collected information to form the basis of judgements in this report in a number of ways; she spoke to two people who live there, the manager, some staff members and the service manager. Some service users and staff records were looked at, along with records relating to the management of the home, some aspects of health and safety, medication and some policies. The inspection focused on the last requirements and recommendations made and what progress had been made towards these since the last inspection. The previous inspection was in October 2005 and covered the majority of the core standards, so for the purposes of this inspection only core standards that were previously not assessed were looked at and the inspection focused on the care planning process and work made towards this and the previous requirements. This report should be read alongside the report of the previous inspection of 24 October 2005. The inspector would like to extend her thanks to everyone who helped with this inspection. What the service does well: The staffing levels are maintained by a permanent staff group, shift cover in unforeseen circumstances like sickness, can be provided for by the reserve staff group and making use of staff from other homes, therefore there is little or no need to use agency staff. The service is supported by an acting manager, who has been in post 18 months and will shortly be applying for her registration as the permanent manager. The downstairs communal area is going to be re-carpeted and then redecorated with in the next few months, providing a more pleasant area for the service users to enjoy. The staff support people to have the personal support they require in a way that they choose and enjoy supporting them to take part in activities. The staff have established relationships with the people who live there and from these relationships, they are able to use their personal knowledge to work in a positive way with people. Great Wood Road, 1 DS0000016922.V280946.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. Great Wood Road, 1 DS0000016922.V280946.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 Great Wood Road, 1 DS0000016922.V280946.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): 1, 2, 5 Service users are currently not supported by a service users guide as this is still being developed. Without this document and with the work still needed in developing systems to assess individual’s aspirations and needs, service users cannot be confident that their needs will be met. Service users need to have individual contracts and/or statements of terms and conditions within the home developed. EVIDENCE: The manger has worked hard to develop a Statement of Purpose and this now includes all the requirements made in this area at the last inspection. It would be beneficial to the service users if this document was also available in a service users accessible document, taking on board the needs of the service users, who all have learning disabilities. The Service User Guide is being developed at a service level and is currently not available; again it is important that this document particularly be available in various mediums that meet the service users communication needs. It was noted during the inspection that service users did not have contracts or statements of terms and conditions available to them, the service manager advised this was being developed and would be in place shortly. This document needs to include the cost of the fees payable each week and any details of the top up fees service users are responsible for. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 9 It also needs to include what arrangements are in place to support service users to have at least an annual holiday. This is of particular importance as service users have not been on holiday for two years. This is due to an issue with the staff and management about what contractual arrangements are in place for staff to take service users on holiday. This matter needs resolving as a matter of urgency as it detrimentally affects the service users quality of life. Birmingham City Council contracts with the home to provide this service. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 9, 10 More work is required so service users can be confident that all their assessed and changing needs and personal goals are reflected in their individual plan. Service users are supported to make decisions about their lives with assistance from staff, this could be further improved. The care planning and risk assessment process has improved, however some more work is required in this area. Service users can be confident that information about them is handled appropriately and their confidences kept. EVIDENCE: Service users in this home have complex needs and are reliant upon staff to interpret their non-verbal communication, to ensure their needs and wishes are met. During the inspection staff were observed to be working along these lines with service users and encouraging them to make choices. There was lots of symbolised information within the home including a photo board for service Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 11 users detailing what staff were on duty each day. The acting manager said that the staff were currently working with service users and the speech and language therapist to develop further forms of communication for the service users. One-service users was noted to have had the opportunity to make use of communication aides that the staff said worked very well for her. These are now going to be bought for her to use on a daily basis. All four service users files were looked at as part of this inspection. It was positive to note that a lot of work has been undertaken in this area and the care plans and risk assessments were of a more satisfactory nature. However it is required that these documents be expanded upon, to include all details of service users needs and preferences and these have clear details on them, of all the actions staff must take to meet needs and manage risks. Care plans should be cross referenced with risk assessments, clearly directing the reader from one to the other, ensuring service users are enabled through this process receive a full package of care. It is required that where possible service users be involved in their plans of care, where it is not possible to involve service users, involving relatives/carers and/or a service users representative is required. It is recommended in line with the Governments strategy in Learning Disabilities, outlined in the white paper ‘Valuing People’ all service users are supported to have a Person Centred Plan. This would support service users to feel confident that their aspirations and needs are recognised and met. All but one manual handling risk assessment has now been completed to a good standard, however these documents must be signed and have a review date in place, there must be space on the form to add comments re changes to these documents from any reviews. There was still no risk assessments in place for the use of bed rails, it is required that this be completed immediately, however the possible injury caused to the service users by the use of bed rails is reduced by the use of bed rail protectors. To support the acting manager in her role as manager and to help her work more effectively in the important area of risk assessment, it is required that she is supported to undertake an accredited risk assessment course. There are systems in place to review service users plans of care every 8 weeks by the key workers and the forma for completing these is an extensive document. It was noted however that these were not being regularly completed by key workers. The manager is working hard on this issue to address why they are not being completed with individual key workers. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 12 Daily records for service users were looked at, these are now legible but it was noted that these were not always completed. During the inspection it was noted that staff were respectful towards service users in all of their communication with them and about them and all information pertaining to service users and the running of the home was stored appropriately. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 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 the following standard(s): 13, 15 Service users are supported to take part in activities in and around their local community and are encouraged to have appropriate personal and family relationships. EVIDENCE: All but one of the service users were out at day centres when the inspector visited. The other service user was going out that morning into her local community to go shopping. All the service users have complex needs and require full staff support to access their local community. The acting manager said the staff work hard to take the service users out on a regular basis in their local community. The acting manager said they regular use the community facility ‘ring and ride’ to support service users with going out and about in their local community. Activities remain ad hoc and the acting manager said that they were working with key workers to look at planning activities more to address service users Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 14 likes and choices around activities and develop individual weekly planners for the service users activities. The acting manager said that she and the staff encourage the service users to have and maintain good relationships with their families/relatives and there is regular contact between service users and their families. Service users maintain relationships with their friends through their attendance at the local day centres. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 15 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 personal care in the way they prefer and require their independence and dignity is promoted. Service users physical and emotional health needs are met. Service users are supported and protected by the home’s policies and procedures with the administration of medication. EVIDENCE: It was evident in all the service user files sampled that a lot of work had been completed in respect of care planning, these care plans detailed the preferences of the service users and what support they would require. However as said in the under the section of the report entitled ‘Individual Needs and Choices’, some further work is required in this area, to ensure all service users needs are specified. It could be demonstrated in the service users files that service users are well supported with their health needs, accessing a range of medical appointments supported by staff, to ensure their health and well being. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 16 Whilst their were few concerns about the staff supporting the service users with their health needs, it is recommended that all the service users be supported to have individual Health Action Plans, as detailed in the Governments National Strategy, out lined in the white paper ‘Valuing People’. Areas including the regular monitoring of service users weight is still required to be done on a monthly basis, and care plans need to be developed to support one service user with appropriate skin care to prevent skin break downs. This should be addressed through a ‘ waterlow’ assessment and this then needs to be supported by care plans detailing what action staff should take to prevent skin breakdowns. It is recommended that all service users be supported to have individual ‘waterlow’ assessments to ascertain what risk if any, service users are at from skin soreness and/or breakdown. This is particularly relevant to service users with any weight issues, mobility problems and/or incontinence. There has recently been a drug error, this situation was thoroughly investigated and appropriate action taken to prevent this from happening again. The manager undertakes regular audits of medication. Medication was found to be safely stored in service users rooms, this method of storing medication reduces the possibility of errors and drug cabinets were found to clean on this inspection. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 17 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 Service users can be confident that their views are listened to and acted upon. Work has been undertaken to ensure service users are protected from abuse and self-harm. EVIDENCE: The complaints policy was seen in the home, this had CSCI relevant contact details. It was noted that each service users had an accessible post-card in their rooms, detailing how to make a complaint. The service manager said that the complaints policy was also available in a tape cassette to service users. There have been no complaints since the last inspection. It is recommended that key workers undertake individual work with service users supported by the speech therapist to support them to understand their rights to complain under the complaints policy. Where this is difficult given the service users complex communication needs, it is recommended that service users family/relatives be involved in this process, this should be then documented on service users files. The acting manager said that all staff have now received Vulnerable Adult Protection Training, this was not checked on all staff files. All staff have to under go training in this area in the form of refreshers every two years to ensure they are up to date and clear about their obligations and responsibilities under Vulnerable Adult Protection procedures. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 18 New staff must undergo training in this area within 6 months of taking up post with the organisation. There was a copy of the Birmingham Multi-Agency Guidelines, of what to do in the case of an adult protection issue; this was clearly displayed on the staff notice board. The acting manager also said that there was an available copy of the Department of Health, white paper ‘No Secrets’. There have been no POVA referrals since the last inspection, and accidents forms have been amended to include body maps to record any unexplained bruising found on service users. Any unexplained bruising and/or marks would require following up, any concerns about marks with unknown causes should be reported under the POVA guidelines. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 19 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, 29, 30 The home was not clean and hygienic. EVIDENCE: A tour of the home was undertaken, with the purposes of following up upon the previous requirements. The inspector brought up with the acting manager that the carpets were in clear need of hoovering and that there were food crumbs throughout the hallway leading to the service users bedrooms. It was also noted that in one service users bedroom the sink had medication spills around the sink bowel. There also remains the need to look into providing a private garden area for service users to enjoy, this needs to be free from hazards and offer a private space. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 20 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): 31, 32, 35, 36 Service users benefit from a staff team who are aware of their roles and responsibilities. Service users are generally supported by a competent and qualified staff team, who are able to meet the individual and joint needs of the service users. Further training and development of staff and regular supervision will enable service users to benefit from a trained well-managed staff team. EVIDENCE: The acting manager said that the home benefits from regular staff meetings where staff roles and responsibilities are discussed along with issues pertaining to service users. The service manager and another experienced manager are supporting the acting manager on a regular basis with staff management, as she is new to her role. Whilst this is a positive process and is supporting the acting manager with her development this needs to be formalised into a regular plan for her development so this can be reviewed and her strengths and needs can be identified and supported effectively. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 21 The acting manager is undertaking work with the staff team to support them with their roles and responsibilities in the areas of the key worker role and initiating activities and personal and health care support they provide for the service users. The acting manager needs to work across the shift patterns on a regular basis to ensure she has an over view of the management of the staff team and the support needs of the service users. The acting manager is further assisted by the appointment of a assistant team leader who will be supporting her to continue to meet the requirements of the this and the last inspection as well as supporting her with the management of the staff and the home. The training records for two staff were looked at. There is a comprehensive training programme provided for the staff by the organisation, in the areas of LDAF, Care of Medicines, Person Centred Planning, HIV/AIDS awareness, Understanding Sexuality, Diabetes, Epilepsy/Rectal Diazepam, Adult Abuse & Protection, Patient Care Handling, Support Plan Training, Autism Awareness, Key Working & Care Planning, Advocacy, Essential Lifestyles Planning and Communication at Work. The organisation provides core training in Data Protection, Health and Safety, Manual Handling, Fire safety, Violence and Aggression, Equality & Diversity and a Central Induction. All new staff are supported to undertake their LDAF award and over 50 of the staff team have their NVQ 2 and the acting manager is currently undertaking her NVQ 4 in management. However it was noted on the training record looked at, that the staff have not attended many of these courses, and the requirement that staff attend their food hygiene course is still outstanding. A training matrix also needs to be developed for the service, detailing what courses staff have completed, when refreshers are due, the length of the training course being provided and who is providing the training. As a good practice guideline it is recommended that a copy of all course contents detailing what is covered in the course is kept with the training file. Supervision of the staff is still not happening on a regular basis, which means staff are not as clear about their roles and responsibilities as they could be and this has a negative impact on the quality of life the service users receive. It is required that staff have regular supervision promoting their effectiveness as staff members and meeting the needs of the service users, this should take Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 22 place at least six times a year, where there are specific issues with staff it is recommended that this happen on a more frequent basis. It is required that the acting manager and assistant team leader are supported to go on a supervision course to enable them to meet their responsibilities in this area more effectively. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 23 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, 41, 42 The service users benefit from a generally well run home. The service needs to develop a quality assurance system, and ensure service users views underpin this process. The health and safety of the service users are generally promoted and protected; however further work is required to ensure this in the area of record keeping. EVIDENCE: The acting manager has worked hard to meet the requirements of the last inspection and she is very committed and enthusiastic. She is motivated and works hard to develop the service and ensure the practices in the home meet the requirements and are of a good quality. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 24 She is clearly committed to working in a away that supports service users best interest, however there is a large amount of work to complete and she will need the support of her line management and the staff team to achieve this. The service currently has no quality assurance system, a quality audit needs to be developed, that supports the service to produce an annual report. This should involve all interested parties including, service users, relatives and/or carers, staff and involved professionals. This will ensure the service is reviewed and developed to look at how best to support the service users involved. Some areas of record keeping remain in need of improving, accident forms being kept appropriately, risk assessments particularly and care plans need some further work. The acting manager had completed all the work from the fire officers report and had a fire risk assessment in place, regular drills were undertaken as well as weekly tests on the fire alarm system, emergency lighting was checked monthly and staff’s fire training was completed twice a year. The acting manager had also completed a day and night evacuation plan. The Portable electrical Appliance Tests had been done for the year and there was a Gas Landlord Certificate in place. Water temperatures are checked weekly and recorded as completed. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 25 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 2 2 2 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 2 30 2 STAFFING Standard No Score 31 3 32 2 33 X 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 3 LIFESTYLES Standard No Score 11 X 12 X 13 2 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 1 X 2 2 X Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 17 (2) Sch 4 Requirement The registered person is required to produce a service users guide that includes; Summary of the Statement of Purpose. Terms and conditions in respect of accommodation to be provided, including amount and method of payment. Standard form of contract Most recent inspection report Summary of complaints with CSCI contact details 2. YA2 4 Previous timescale 01/06/05 The registered person must 01/07/06 produce an admissions policy, including emergency admissions. Previous timescale 01/05/05 The registered person must 01/07/06 ensure a contract is developed for each service DS0000016922.V280946.R01.S.doc Version 5.1 Page 27 Timescale for action 01/06/06 3. YA5 5 (b)(c) Great Wood Road, 1 4. YA6 17(1)(a) Sch 3 users detailing the terms and conditions of their stay in the home, this must include details of fees payable and what arrangements are in place to provide service users with annual holidays. The registered person must develop service user plans to include: Detailed up to date care plans, which are subject to review. These must include the goals and aspirations of service users activity plans and monitoring of such. 01/07/06 5. YA6 17(1) Sch 3 Previous timescale 01/06/05 extended 01/05/06 The registered person must ensure 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 and response to care. 6. YA7 12(3) 7. YA9 13(4) Previous timescale 01/06/05 The registered person must ensure it is demonstrated how service users are involved in their plans of care and where this is not possible, how their relatives or representatives are involved. The registered person must ensure further development of risk assessments is required. These include; 01/07/06 01/06/06 Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 28 - The acting manager must attend an accredited risk assessment course. - Existing controls are crossreferenced 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 its continuation in its present form - A risk assessment must be put in place for the use of bed rails. 8. YA13 16 (2)(m) Previous timescale 01/06/05 The registered person must develop service users activities more and link these into activities that are planned around supporting service users in their local community. The registered person must DS0000016922.V280946.R01.S.doc 01/07/06 9. YA17 16(2) I 01/06/06 Page 29 Great Wood Road, 1 Version 5.1 ensure the diet provided to service users is varied and nutritious. The home is waiting on a referral to the dietician. Previous timescale 01/05/05 – extended not inspected on this occasion The registered person must ensure service users are involved wherever possible in determining meals and alternative choices Previous timescale 01/05/05 – extended, not inspected on this occasion The registered person 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 and assistance. The registered person must ensure that where there are concerns about pressure area care or continence management, that these are referred to appropriate professionals for advice and assistance. The registered person must ensure, the use of 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 01/05/05, not inspected on this occasion. The registered person must DS0000016922.V280946.R01.S.doc 10. YA17 12(3) 01/06/06 11. YA19 14(2) 15 01/05/06 12. YA19 14(2) 15 01/05/06 13. YA23 13(7)(8) 01/05/06 14. YA24 23(2)(a) 01/08/06 Page 30 Great Wood Road, 1 Version 5.1 ensure that the garden area that offers little privacy for service users has appropriate screening or other means must to address this. Previous timescale 01/06/05 – extended. The registered person must ensure steps must be taken to address the uneven paving in the garden, which present a trip hazard Previous timescale 01/06/05 – extended. The registered person must ensure carpets throughout the home are replaced within the next few weeks. The registered person must ensure the two bedrooms identified need to be redecorated. Previous timescale 01/06/05 – extended not inspected on this occasion. The registered person must ensure service users bedrooms 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 01/06/05 - not examined at this inspection. The registered person must replace the hospital bed, with a bed that is suitable for the needs of the service users, and is as domestic in nature as possible. DS0000016922.V280946.R01.S.doc 15. YA24 23(2)(o) 01/06/06 16. YA24 23(2)(d) 01/04/06 17. YA25 23(2)(d) 21/01/06 18. YA26 23(2)(c) 01/04/06 19. YA29 16(2)(c) 23(2)(c) 01/07/06 Great Wood Road, 1 Version 5.1 Page 31 20. YA29 13(4) The registered person must 01/05/06 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 and a copy of the risk assessment completed. The registered person must ensure that the home at all times is kept clean and hygienic. The registered person must ensure that staff are confident in the content and provision of policies and procedures in respect of: - Sexuality - Their role in facilitating complaints for service users 21 YA30 13 (3) 01/04/06 22. YA32 18(1)(c) 01/05/06 23. YA35 18(1)(a, c) Previous timescale 01/05/05. The registered person must ensure training be provided to all care staff to include: - Hygiene and food handling Previous timescale 01/06/05 – extended. The registered person must ensure that staff receive regular supervision, at least a minimum of six times per year. The organisation must ensure the acting manager is supported in her role, by providing supervision training for her and the assistant team leader. Previous timescale 01/06/05 - extended The acting manager should work across all shifts in the DS0000016922.V280946.R01.S.doc 01/05/06 24. YA36 18(2) 01/06/06 25. YA36 18(1) 01/04/06 Great Wood Road, 1 Version 5.1 Page 32 26. YA37 8 9 24 (1a,b)(2)(3) 27. YA39 28. YA41 17(2) Sch 4 home to ensure sufficient management oversight. The acting manager must apply to become the registered manager of the service. The registered person must ensure a quality assurance system is put in place, that supports service users to feel confident that their views underpin all self-monitoring, reviewing and development of the home. The registered person must ensure that accident records are compliant with the Data Protection Act 1998 01/07/06 23/06/06 01/04/06 29. YA42 13(5) 30. YA42 16(2)(j) Previous timescale 01/05/05 – extended The registered person must 01/05/06 ensure that the further development required in the area of manual handling risk assessment for one service user is completed; all risk assessments in this area must be regularly reviewed for all service users. The home must ensure that 01/04/06 fridge and freezer temperature checks include: The acceptable range for temperatures Action taken to address variances from the acceptable range. Action must be taken to defrost the freezer when it becomes overly frozen. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 33 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. Refer to Standard YA7 YA19 YA39 Good Practice Recommendations All services users need to be supported to have a Person Centred Plan. The service users should be supported to have individual Health Action Plans. It is recommended that the manager explores how task can be delegated to staff to further facilitate compliance with requirement as well as participation and understanding of the staff team. Great Wood Road, 1 DS0000016922.V280946.R01.S.doc Version 5.1 Page 34 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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