Inspection on 06/12/05 for 1 Whitehall Road

This inspection was carried out on 6th December 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Whitehall Road 12/03/07

1 Whitehall Road 27/02/06

1 Whitehall Road 10/03/05

1 Whitehall Road 19/11/04

1 Whitehall Road 01/03/04

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 1 Whitehall Road, Cradley Heath West Midlands B64 5BG Lead Inspector Mr Jon Potts Announced Inspection 6th December 2005 10:00 1 Whitehall Road, DS0000004843.V262426.R01.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 1 Whitehall Road, DS0000004843.V262426.R01.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. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 1 Whitehall Road, Address Cradley Heath West Midlands B64 5BG 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) 01384 357933 NONE info@Inshoresupportltd.com Inshore Support Mr Adam Webb, Mr Ian Forrest-Jones Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2005 Brief Description of the Service: 1 Whitehall Rd is an adapted terraced property that was refurbished for the purpose of providing long term care for three younger adults with a learning disability. The house is positioned in an established residential area within walking distance of the centre of Cradley Heath. Accommodation briefly comprises of three single bedrooms (two which are ensuite), bathroom, two lounges, dining room and kitchen. The building has a small rear garden area. The home is managed by Inshore support, a company that has a number of small homes that have similar aims and objectives to Whitehall Road. The staffing in the home consists of a manager, senior support and support workers. The staffing ratio is at least one staff member to one resident at day and night, although this is higher for support within the community. The home has an appropriate car allocated for the transport of the residents. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out between 10.00am and 4.00pm and involved the acting manager, two residents and staff. Information/evidence was drawn from case tracking, staff files, and sight of documents, policies and procedures. Information was also drawn from a pre – inspection questionnaire completed by the acting manager and relatives questionnaires. What the service does well: What has improved since the last inspection? What they could do better: There are still a number of areas where improvement is needed. Of primary importance is the need to identify an appropriate manager who will submit an application for registration so as to provide some much needed stability for the home. There are areas where documentation needs to be better, this including care plans that better tie in with recent assessments, clarity in all plans as to the exact methods for any physical intervention, more overt recording of areas where residents are limited by risk assessment, better activity planning, evidence of residents/representatives involvement in care planning for all 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 6 residents, clear consent to medication for all residents and recording monies taken off the premises. The staff need to arrange the involvement of one resident with an optician (according to the care plan) and there needs to be more staff qualified to NVQ level 2 or above. There is one area of the home that was found to contain an unpleasant odour, this needing action and checks of smoke alarms need to be more frequent. There is also a need for the homes 5 yearly electrical hard wiring safety check to be carried out, as this is overdue. 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 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 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 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 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): 1,2,3,4,5, Information about the home is available to prospective residents, although there is not always opportunity to ‘test drive’ the home. Prospective and existing residents individual aspirations and needs are assessed, although confirmation of the homes ability to meet these is not always provided prior to admission. Each resident has an individual written contract/lifestyle agreement with the home, these not all signed by residents however. EVIDENCE: A copy of the homes statement of purpose/service users guide was seen during the course of the inspection, this containing a range of information about the home for prospective users. The provider is looking at adapting this document so that it is available in other formats, this partly addressed with pictorial information available about what the staff can do for residents etc. It was stated that the information is also available on audiocassette although this was not seen/heard by the inspector and was stated to be available from the provider’s head office on request. Comments from the resident’s relatives indicate that they do not have access to inspection reports by CSCI. The provider should facilitate this access. The home was seen to have detailed pre-admission assessment information in place from the purchasers of the service (local authorities), although the home 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 9 had not confirmed its ability to meet the last admitted resident’s needs prior to admission as must be the case. The home was seen to have completed its own assessments on a recently adopted format, these detailed and updating original pre admission assessments. Not all this information was however carried through to care plans. One resident had not received a multidisciplinary review in the last twelve months although the acting manager was aware of this issue and the date was now set for January 2006. One resident was admitted to the home since the last inspection, although when requested there was no evidence available to show that the home had introduced the resident so as to enable them to test drive the home. The acting manager stated that due to specific circumstances this had not been possible (this agreed by the social worker), although to date the inspector has seen no documented evidence to confirm this. Terms and conditions (called lifestyle agreements) are available to residents these containing all the necessary details expected. Out of the lifestyle agreements seen, one was not signed, this requiring the signature of the resident or their representative. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 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 Not all the resident’s changing needs (as identified in assessments) are reflected in their individual plans. Residents make decisions about their lives with necessary assistance, and are supported to be as independent as is possible. The home has clear protocols for the handling of information in respect of residents. EVIDENCE: Care plans are in place for all residents, one of these examined in depth at the time of the inspection. Some of the plans (in respect of managing behaviours and daily routines) were very detailed and information from reviews and assessments had in some cases influenced the update of these documents. Recently completed assessments completed had not however been fully carried through to care plans. There was seen to be two different formats for care plans with the 2nd format (not a standard inshore support proforma) covering some areas that had questionable relevance and following discussion with the acting manager difficult to achieve goals. The acting manager was advised that 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 11 the plans should be rationalised (so all on the same format that the provider normally uses) and reviewed in light of recent assessments. All care plans also need to be signed by the resident or their representative. There also needs to be more clarity as to where there maybe limitations upon the residents due to risk assessment. The acting manager was advised that an explicit statement as to exactly what these limitations are would be useful for purposes of clarity and understanding. Discussion with/ observation of staff members indicated that they had a very good understanding of the care plan discussed and were seen to implement some of the plan on the day of the inspection. One resident was seen to have some involvement with advocacy services and information in respect of advocacy was seen to be readily available if needed. There was clear evidence from observation of the staff team that information was provided as a matter of course so as to allow residents to make decisions, and some of their specific choices as to day to day life were documented in case files. There was also evidence that resident’s independence was, as far as possible, being encouraged by staff. The individual risk assessments on the case file examined were found to be very detailed and were clearly informing the practices of the staff although the one checklist examined is in need of review (as last review was nearly a year ago). The home was seen to have a clear protocol for access to sensitive information, and documents are appropriately stored. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 12 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): 12,13,14,15,16,17. The residents are supported to have involvement in activities and leisure, a number of these community based. The way activities are provided could be more structured and better related to individual needs and abilities (through documented plans). Residents are supported to have relationships in accordance with their wishes and risk assessments in place at the home. Residents are able to access a healthy diet in keeping with their individual choices, this in pleasant surroundings. The homes procedures highlight resident’s rights and staff respect these. EVIDENCE: Records of the activities the residents are involved in show these are readily made available to them, with a number of these having a community orientation, this assisted by the fact that the home has its own allocated transport. A more structured activity programme must however be developed 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 13 for the residents, this to link into the development of any potential future opportunities for education. There was seen to be information in respect of the resident’s possible involvement in domestic tasks within the home in assessments. The home has developed a policy on sexuality that is drawn from British Institute for learning disability documentation. Arrangements for contact with families are detailed within care documentation, with comments from relatives indicating that they are consulted and kept informed of any matters of importance in respect of the resident. The records of foods taken by the residents indicate that there is an appropriate and well balanced diet made available to them. The home does have a set menu although this is subject to change based on the wishes and choices of the residents on a daily basis, and there was pictorial information as to the meals available. Resident’s likes and dislikes in respect of food were seen to be documented with the record of foods reflecting these choices. All residents have been nutritionally assessed. The home has a charter of rights in place and staff were aware of how residents should be treated so that their rights were respected. Interaction seen between staff and residents showed that was appropriate and in accordance with this charter. The house allows the residents to have access to private space if required for privacy. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Residents receive appropriate personal support and most of their physical and emotional needs are met. The residents right to self-administration are limited following risk assessment, although the homes policies and procedures do protect residents in this area. Not all residents or their representatives have consented to medication. EVIDENCE: Evidence showed records of choices allowed within daily routines in a number of areas, although the care plans did reflect a degree of structured intervention, this appropriate to need. Discussion with staff and observation/listening to staff interacting with residents evidenced staff having a clear awareness of the residents needs and as to how they should communicate with them. The members of staff spoken to and the acting manager showed a good working awareness of the care plans and risk assessments discussed. There was clear evidence of the resident’s choices having been documented in their individual case files. It was clear that all the residents are given personal space as and when they require it, the building allowing for this provision, with a room available for each resident. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 15 There was clear evidence that the residents were assisted to access health services whether specialised or pertaining to routine health not associated with their learning disability. One of the residents had not however seen an optician recently, with mention in the care plan indicating that this contact was necessary due to specific needs relating to their vision. The home was seen to have a policy on medication, this recently revised. Staff that administer medication have received accredited medication training. The homes systems for the administration, storage and ordering of medication were judged to be acceptable with no gaps in medical administration records, clear information available about the medication in use and evidence of audits by the contracted pharmacist. There does need to be signed consent to medication for all residents however, if not by the resident themselves then their representative or such as psychiatrist. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Procedures are in place to support residents or relatives in expressing their views and dealing with any concerns that they may have. Overall the residents are protected from abuse, neglect and self harm by the homes procedures, this supported by staff awareness. EVIDENCE: The home was seen to have appropriate policies in place in respect of complaints. The home has developed a pictorial complaints procedure that carries the phone number for the police, CSCI, Social Services and other managers within Inshore support with photos of one of the latter. There has been one complaint received at the CSCI in the last 12 months, this resolved satisfactorily by the provider. Both relatives that responded to the CSCI survey forms both stated that they were aware of the home complaints procedures. The home had copies of appropriate policies and procedures in addition to the local authorities Protection of vulnerable adults procedure. The members of staff spoken to had a good understanding of the procedures to follow in the instance that they witnessed abuse, and the two spoken to were very clear that they would confront bad practice if seen. The recording in case files showed that any bruising or injuries were documented on body maps, these seen to be completed and containing reference to even minor bruising/injury. Incident report forms are completed where an injury maybe due to non – accidental reasons, such as restraint. The majority of staff have training in approaches to challenging behaviours (called positive approaches). Records of restraint were seen to carry detail of the exact type of restraint that was used when other methods such as 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 17 diversion failed, these not always clear in residents care plans however. The restraint methods were seen to be in accordance with guidance elsewhere in the home in respect of restraint, as drawn from positive approach training information (which was stated to be supplemented by a video of techniques for physical intervention that was available to staff). Spot checks of resident’s monies in safekeeping were carried out and the amounts in safekeeping balanced with the records, which were appropriately documented. The social activity money had been taken out by the senior (for expenditure on resident activities) but was not booked out meaning there was no clear record of the monies held by the senior. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 1 Whitehall Road is a comfortable and overall safe environment that is suitable for the residents accommodated, with communal and private space suitable for the needs of their lifestyles. Overall the house was seen to be clean and with one exception hygienic. EVIDENCE: The home is sited in a suitable position and presents as a homely environment in keeping with the provision of ‘normal’ domestic style living. There is no indication that the house is anything other that a domestic home, this ensuring that it blends into the immediate community. The home has a redecoration and refurbishment programme identifying works for the next twelve months, although there has been a sustained programme of works over the previous twelve months that has greatly improved the physical standard of the property, inside and out. The house presents as very comfortable and provides residents with a good standard of accommodation. One bedroom is slightly undersized but this is compensated for as the house has more communal space than required in the two lounges and dining room. The other two bedrooms, which are also ensuite are also well over the required size. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 19 Suitable arrangements were in place in respect of infection control although it was noted that one bedroom (or possibly the connected ensuite) had a urine like odour that needs to be addressed. The acting manager thought that the cause was the bathroom carpet, although visually the bedroom and bathroom seemed clean. There is no adaptation currently required to allow the home to meet the resident’s physical needs. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 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): 32,34,35 Staff evidenced in discussion a good understanding of their job role. The staff seen presented as competent with an acceptable level of training evidenced but not qualification to NVQ level 2. Resident’s are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The staffing ratios required for the resident’s were seen to be consistent with those stipulated by the purchasers (where stated) and the homes assessments. The inspector judged the staffing ratios at the time of the inspection to be appropriate. Discussion with staff indicated that they had a good understanding of what were the current relevant issues for the residents (based on their care plans) and how to provide an appropriate service that respected quality of life issues. This was further confirmed by observation of staff and interaction between them and the residents. An audit of three staff that had been employed since the last inspection evidenced that all the expected recruitment checks had been carried out prior to employment with the exception of a disclosure in some cases, although the 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 21 acting manager had in these instances contacted the CSCI and completed an appropriate risk assessment. The home was seen to have a training plan that clearly identified training staff held, what was booked and what was needed. Where staff do not currently hold training in mandatory areas, dates for when this is to be provided have been clearly identified. There is currently one out of twelve staff that have completed NVQ level two, this meaning the home is well below the required benchmark of 50 of the staff team so trained. Two more staff have nearly completed their NVQ level 2 training. The home has a structured induction programme in place with an external training company providing input into accredited induction training. One staff member interviewed (recently employed) did state that they felt very well supported by the acting manager and the company in respect of training provision. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 22 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): 37,40,41,42 EVIDENCE: There has not been a registered manager at the home since prior to the last inspection and the previous acting manager has left and has been replaced with another acting manager. Whilst there has been support from other managers this has resulted in a lack of consistency, this situation not improved by a degree of staff turnover. It is however evident that the new acting manager with the support of other manager’s is improving the running of the home, and whilst a number of issues are identified that require attention, there are also numerous areas that have been addressed and improved. It is however vital that an appropriate manager is identified who will submit an application for registration in respect of Whitehall Rd. The homes policies and procedures have developed since the last inspection with a review carried out by senior management in November of this year. The staff are currently reading and signing to say they understand the new policies and procedures, which are readily accessible in the home. There was 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 23 discussion with the acting manager who stated that there is on-going work to develop further policies in a suitable formats for residents that are unable to read. The standard of record keeping has seen to have improved since the last inspection, although there are specific areas where improvement is required as detailed earlier in this report. How the home considers the health, safety and welfare of the residents was assessed through sampling of servicing records, examination of risk assessments, auditing staff training and examining other records (such as accident reports). Arrangements were found to be satisfactory with the exception of: - No smoke alarm checks since the 10th November 2005. The fire prevention officer must be contacted to verify the frequency at which these checks should be carried out. - There was no certificate to evidence that the 5 yearly hard electrical wiring check had been carried out when required in September 2005. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 24 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 3 3 2 2 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 4 3 2 3 4 3 2 LIFESTYLES Standard No Score 11 2 12 2 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1 Whitehall Road, Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 1 X X 3 2 2 X DS0000004843.V262426.R01.S.doc Version 5.0 Page 25 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 YA3 Regulation 14 Requirement Timescale for action 06/12/05 2 YA3 13,14 The home must confirm in writing to the service user or their representative that they are able to meet their needs prior to admission. The registered providers must 31/01/06 ensure that all service users are reviewed at least on an annual basis or when changes occur, this by the social worker from the funding authority This is a repeated requirement. To review and rationalise the care plans so that they tie in with all the information within resident’s assessments. The resident or their representative must also sign all care plans. The registered providers must ensure that any potential limitations on service users due to the need to minimise risk are clearly documented in the individual case file/care plans. This is a repeated requirement. To review the risk assessment DS0000004843.V262426.R01.S.doc 3 YA6 15 28/02/05 4 YA7 12,13,14 28/02/05 5 YA9 13 31/01/05 Page 26 1 Whitehall Road, Version 5.0 check list for resident M.L. 6 YA12 16 A more structured activity programme must be developed for the residents, this to link into the development of any potential future opportunities for education. This is a repeated requirement that was to have been met by 24.4.05. To explore the need for a optician/ophthalmologist for resident M.L. To ensure that consent for medication is gained for all residents, if not from the resident themselves then from their representative or such as psychiatrist. To ensure that the exact methods for physical intervention are detailed in resident’s care plans. When resident’s monies are taken off the premises they must be booked out so that there is a clear record of the monies held by the senior. To address the odour in the one bedroom/bathroom as discussed at the time of the inspection. The registered provider must ensure that support is provided to staff to allow them to achieve NVQ level 2 training and allow the home to reach a ratio of 50 of staff so trained. This is a repeated requirement. The registered provider must ensure that there is an application for registration for the manager’s position to the CSCI. This is a repeated requirement. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 27 31/01/05 7 8 YA19 YA20 13(1) b 12 13(2) 31/01/05 28/02/05 9 YA23 13(6) 15/01/05 10 YA23 13(6) 31/12/05 11 12 YA30 YA32 13(3) 18 31/01/05 30/06/05 13 YA37 8,17 28/02/06 14 YA42 23(4) 15 YA42 23(2) The fire prevention officer must be contacted to verify the frequency at which smoke detectors should be checked. These checks to be carried out as advised. To evidence that the 5 yearly hard electrical wiring check has been carried out. 15/01/05 31/01/05 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 YA4 YA5 YA35 Good Practice Recommendations To document the details of the resident’s introduction to the home. The contract/lifestyle agreement for resident M.L. should be signed on his behalf by their representative. To continue with the training detailed within the homes training plan. 1 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 28 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 Whitehall Road, DS0000004843.V262426.R01.S.doc Version 5.0 Page 29 - 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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