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Inspection on 10/11/05 for 26 Green Road

Also see our care home review for 26 Green Road for more information

This inspection was carried out on 10th November 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 no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff give support with warmth, friendliness and patience and treat people respectfully. The Manager and staff welcome the inspection process and work hard towards meeting CSCI requirements. The home has a nice friendly atmosphere. The home is bright and cheerful. Service user bedrooms are well maintained and personalised. Medication management was in good order. Staff at the home seek input from other health and social care professionals to assist in meeting individual need.

What has improved since the last inspection?

Some shortfalls were identified at the last inspection regarding the admission process of one new resident. However, the admissions policy and procedure has now been updated and hopefully this will guide future good practice. A revised physical intervention policy covers all the areas required in line with the Department of Health`s guidance on the use of physical intervention. Screening at the window has now been provided in the bathroom as required at the last inspection to ensure the privacy of service users. One service user told the Inspector that he had new bedroom furniture, which he had chosen himself. Copies of reports of the visits to the home by the representative of the director of the organisation are now being forwarded to the CSCI. All but one of the previous requirements have been met.

What the care home could do better:

Care documents do not consistently show service users involvement, timely review or how all service users needs are to be met. The Manager needs to ensure that staff who lack confidence in shaving are supported to undertake this task. Further guidance on shaving service users should also be included in the care plan. At the last inspection the Manager stated that Optimum intended to introduce health action plans. This is something that the Government paper, `Valuing People` recommended that each person with a learning disability had by 2005. This has not been done for all service users. Some Health and Safety matters require attention, to include electrical and transporting service users. All areas of risk must be assessed. The Provider must review the transport arrangements to ensure that the Manager has adequate resources to enable service user activities away from the home to take place. The premises has several design shortfalls that affects service delivery to service users. A review of the premises is needed and plans developed to ensure the design is better suited to meeting the needs of the service users. Effective monitoring of weight and bowel movements is required where this has been an identified need for service users.

CARE HOME ADULTS 18-65 Green Road, 26 Hall Green Birmingham West Midlands B28 8DD Lead Inspector Kerry Coulter Announced Inspection 10th November 2005 09:45 Green Road, 26 DS0000016884.V257166.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 Green Road, 26 DS0000016884.V257166.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. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Green Road, 26 Address Hall Green Birmingham West Midlands B28 8DD 0121 777 2896 0121 777 2896 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) Optimum Care Services Mr Timothy James Burgwin Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 10th May 2005 Brief Description of the Service: 26 Green Road is a detached chalet style bungalow located in a quiet residential area in the south of Birmingham. The home is within walking distance of a range of amenities and is close to both bus and rail routes to the city. Accommodation for residents comprises of four single bedrooms on the ground floor and one en-suite bedroom on the first floor. The bedrooms vary in size, all are personalised to individual tastes and preferences. There is a large wooden panelled lounge with television and music centre. This room also has a dining area. The home has a large fitted kitchen with a small dining area, two bathrooms, a very small office/ sleep in room and an outbuilding used as a laundry. The home has a large garden to the rear of the premises with lawned areas, flowerbeds and a barbecue area. There is limited off road parking to the front of the home with additional parking available on the road. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this announced inspection over six hours. This was the second of the statutory inspections for this home for 2005/2006, to get a full picture of this home this report should be read in conjunction with the report of May 2005. The Inspector was pleased to meet with all of the service users that live at the home during the inspection, the staff on duty, Manager and one relative. The Inspector looked at all the communal areas of the premises, and all bedrooms. The Inspector spent time talking to service users and observing the support and interaction between them and the staff. The Inspector looked at the records of care and care plans for two of the people who live in the home. Other records including fire safety records, rotas, staff supervision and training were also inspected. Information was provided by the Manager on the CSCI pre inspection questionnaire. What the service does well: Staff give support with warmth, friendliness and patience and treat people respectfully. The Manager and staff welcome the inspection process and work hard towards meeting CSCI requirements. The home has a nice friendly atmosphere. The home is bright and cheerful. Service user bedrooms are well maintained and personalised. Medication management was in good order. Staff at the home seek input from other health and social care professionals to assist in meeting individual need. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Care documents do not consistently show service users involvement, timely review or how all service users needs are to be met. The Manager needs to ensure that staff who lack confidence in shaving are supported to undertake this task. Further guidance on shaving service users should also be included in the care plan. At the last inspection the Manager stated that Optimum intended to introduce health action plans. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This has not been done for all service users. Some Health and Safety matters require attention, to include electrical and transporting service users. All areas of risk must be assessed. The Provider must review the transport arrangements to ensure that the Manager has adequate resources to enable service user activities away from the home to take place. The premises has several design shortfalls that affects service delivery to service users. A review of the premises is needed and plans developed to ensure the design is better suited to meeting the needs of the service users. Effective monitoring of weight and bowel movements is required where this has been an identified need for service users. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 7 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. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 8 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 Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 9 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 and 2 The Statement of Purpose and Service User Guide provide prospective service users with relevant information about the home to enable them to make a choice about if they want to live there. Written procedures ensure that assessment of new service users will be completed prior to admission to ensure the home is suitable for their needs. EVIDENCE: The home has a statement of purpose and service user guide in place that meets the required standard. A copy of the homes service user guide had been provided to all service users, this is in a format that contains pictures and photographs. Some shortfalls were identified at the last inspection regarding the admission process of one new resident. No new service users have moved into the home since then and so it was not possible to assess current practice. However, the admissions policy and procedure has now been updated and hopefully this will guide future good practice. Green Road, 26 DS0000016884.V257166.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, 9 and 10 Care documents do not consistently show service users involvement, timely review or how all service users needs are to be met. Information is stored and transmitted in a sensitive, confidential way. EVIDENCE: Two service user files were sampled. The care plans were observed to be well constructed and generally up to date, thus ensuring that staff have most of the required information to enable them to meet individual need and provide consistent care. However some guidelines in place were observed not to be dated, it was therefore not evident how current these guidelines were. Some areas of the care plan required further detail to be included about the exact type of support required at meal times and for shaving. One relative had concerns that the initial placement was supposed to be temporary pending a move to another home being opened by Optimum. Unfortunately the new home is yet to be registered and the service user is still at Green Road. The minutes of a review meeting held for this service user recorded that he had some weight loss and anxiety was a possible contributing factor to this. There were no actions agreed or guidelines available about ways in which staff could try and reduce his anxiety. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 11 Additionally, although the review had taken place there were no goals or actions arising from the meeting and it was unclear how the service user had been included. A wide range of risk assessments had been completed, all those sampled were up to date and recorded the likelihood of the risk occurring. Further attention has been given to highlighting the level of risk using a colour coded system. For one service user the risk assessments were clearly cross referenced with the care plans but in the other file sampled this had not been done. Each risk assessment should be directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other. One of the outcomes for completing risk assessments and care plans should be that the finished article is a simple and effective working document, in which essential information can be easily found. Some service users have been on holiday this year. Discussion with the Manager indicates that a risk assessment had not been completed for the holiday. Before any holiday takes place areas such as the environment, staffing levels, medication storage arrangements, medical arrangements and arrangements for the disposal of clinical waste should be assessed. On the day of the inspection the confidential records pertaining to the service users were securely kept, indicating good practice on behalf of staff handling of tenants confidential information. No inappropriate communication between staff about service users was observed. All observed staff interaction with service users appeared positive and respectful. Green Road, 26 DS0000016884.V257166.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, 15 and 17 Service users are offered opportunity to access the community, and undertake developmental activities, however recent changes in the availability of transport have had a negative impact on some activities taking place. Service users are supported to maintain contact with their family and friends. Service users are offered a balanced diet but the availability of alternative meals is not evident. EVIDENCE: Service users have a planned timetable for attendance at activities outside of the home that includes attending college courses. The home lost the use of a people carrier in the summer months and for some time had to rely on either public transport or taxi’s. This resulted in some service users missing out on planned college courses. After some delay the home has been provided with a car as a temporary measure. Discussion with several staff indicates that although having the car is an improvement it is not ideal in meeting the needs of the service users. The Provider must review the transport arrangements to ensure that the Manager has adequate resources to enable service user activities away from the home to take place. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 13 Since the last inspection some changes to the activities on offer have been made. Visits to the home by an art therapist have been reintroduced and service users have started on the Handsworth College Programme. Changes have also been made to the activity programme board in the kitchen. This is now in picture/photograph format informing service users of their planned activities for the day. One service user said he had been to see ‘Fame’ the musical, which he had enjoyed. Throughout the day service users were observed to be engaged in activities, this included domestic tasks, Progressive Mobility (music & movement) and hand massages. One relative spoken with said his brother now participated in more activities than where he previously lived. Discussion with staff and sampling of records evidence that staff support service users to maintain links with friends and family. Examples include writing to friends at another care home and telephone calls to relatives. A visitor’s file is located in the hallway. This contains the statement of purpose, CSCI reports and comment cards for visitors to use on their views of the service provided. One relative spoken with was happy with the overall care provided at the home. The food records sampled evidenced there was a good variety of meals on offer. Food stocks in the home were good and there was fresh fruit and vegetables available. Service users were observed to be appropriately supported by staff to eat their lunch. Staff ate with service users and the atmosphere was relaxed with service users included in conversation. One service user has recently received input from the Speech and Language Therapist regarding his meal time support needs. Records for one service user indicate that he sometimes refuses meals offered. This service user has also had some weight loss. It was therefore of concern that food records did not always evidence that alternative meals are offered when a meal is refused. The Manager said that alternative meals are always offered and that he would ensure staff recorded this. One comment card received from a service user recorded that they could choose what they wanted to eat. Green Road, 26 DS0000016884.V257166.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 and 20 Care plans require further detail regarding some aspects of personal care. The health needs of service users are generally met but some areas require improved monitoring. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure residents receive the medication they need. EVIDENCE: It was not evident that all service users had been supported with personal care. Two service users were observed not to have been supported to shave. Staff said that this was because the service users had both not stood still when attempting shaving and that staff lacked the confidence to shave them. Staff said they were awaiting a male care staff to come on duty in the afternoon and then they would be shaved. However the Manager was on duty in the morning and staff could have asked him to assist. The Manager needs to ensure that staff who lack confidence in shaving are supported to undertake this task. Further guidance on shaving service users should also be included in the care plan. Service users are supported to health care appointments and records of these are well maintained within separate consultation forms. However some weight records and bowel charts were not being completed as needed. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 15 There was documented evidence that the majority of health care needs were being identified and followed up. One service user has a health action plan that has been completed with the involvement of the Community Nurse. Staff stated that it was intended that similar plans would be completed for all service users in line with the Government paper ‘Valuing People’. Medication management was in good order. A record of medication received was available. The medication administration records (MAR) were sampled for all service users who live at the home. These were observed to be satisfactory. All medication was being acknowledged when received and two people signed when it was administered. Staff now photocopy and retain a copy of the prescription before it goes to the pharmacist. The manager has introduced stock control and auditing systems to ensure that service users are receiving the correct medication. Staff have received medication training, new staff are also booked to attend training. Green Road, 26 DS0000016884.V257166.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): 22 and 23 The home has a satisfactory complaints system with some evidence that service users are listened to. Adult protection procedures show that service users are being protected from abuse and that their welfare is being promoted. EVIDENCE: The home has satisfactory complaints procedures in place, this includes a ‘listen to me’ document provided to service users. There is evidence of service users being listened to, this procedure has been used recently with regards to the transport issue at the home. The adult protection procedure is generally satisfactory with a quick reference flowchart that includes the contact name and number of the homes local Vulnerable Persons Officer from West Midlands Police and relevant Social Workers and area offices. A revised physical intervention policy covers all the areas required in line with the Department of Health’s guidance on the use of physical intervention. Discussion with the manager indicates all staff have received adult protection training. Service users money was observed to be kept in a secure place when not in use. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 17 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, 26, 27, 28 and 30 The premises has several design shortfalls that affects service delivery to service users. EVIDENCE: The environment is not suitable for the needs of the service users as the home has a combined lounge and dining area. It has previously been recommended that the organisation provide an additional communal area where visitors could meet service users in private or to provide a quiet area for service users. Recommendations from the Speech and Language Therapist include the provision of an extra communal room within the home, as this individual can on occasion be very vocal. This has an impact on other service users in the home. A room is provided for staff that sleep in. Space for the storage of staff’s personal belongings is limited as this room is small and also doubles up as the office. The home’s office does not comfortably accommodate more than two people, meetings are therefore held in the kitchen or lounge/diner. The home does not have an internal laundry. The laundry facilities are situated in an outbuilding at the side of the house and staff and service users have to go outside to access the laundry. This is not adequate. The organisation must consider re-sitting the laundry or provide a covered walkway. Optimum does not own the property and are therefore reliant on the landlords of the property to make the required changes. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 18 Some areas of the home require minor repairs. The kitchen floor covering still requires repair or replacement due to a damaged area adjacent to the cooker. Two chairs in the lounge have torn coverings, the Manager said funding for their replacement has now been agreed. The lighting in the hallway is not adequate. The Manager said that the home has experienced problems with the lights blowing and provided evidence that an electrician had visited the home to investigate the problem. His recommendations needs to be actioned. Bedrooms are nicely decorated and personalised. One service user told the Inspector that he had new bedroom furniture, which he had chosen himself. Another bedroom was in the process of being redecorated. The home has a sufficient number of bathrooms and toilets for five service users. One bathroom has the facilities of an assisted bath. There are locks on the bathroom doors and these can be opened from the outside in an emergency. Screening at the window has now been provided in the bathroom as required at the last inspection to ensure the privacy of service users. All areas of the home observed were clean and free from offensive odours. Food in the fridge was observed to be date labelled when opened to ensure staff know when it requires discarding. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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, 35 and 36 Service users are supported by a core team of stable and knowledgeable staff, a period of staff shortages has meant staff working long hours to support service users. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company. Staff give support with warmth, friendliness and patience and treat people respectfully. The home has undergone a recent period of staff shortages. Discussion with the Manager indicates that some new staff have recently commenced work in the home with another member of staff due to commence work soon. Sampled rotas indicate that some staff have been working exceptionally long hours without adequate rest periods, this must be reviewed. Staff files sampled all contained application forms, proof of identity, written references and CRB checks. However for one member of staff the Manager was unable to locate a copy of a POVA check, this was forwarded after the inspection. Three staff at the home have achieved an NVQ in care. The Manager will need to ensure that this number is increased to meet the target of 50 of staff achieving an NVQ. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 20 Staff have received mandatory training in areas such as fire, first aid, health and safety and food hygiene. Discussion with the Manager indicates that training opportunities in recent months have declined due to being unable to release staff as the rota needed covering. The Manager hopes that now new staff have been recruited training opportunities can be increased. Staff are given satisfactory levels of supervision to enable them to carry out their role effectively. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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): 39 and 42 Work practices in the Home generally promote and protect service user’ welfare, health and safety but attention is required to electrical safety and the use of staff cars to transport service users. EVIDENCE: Copies of reports of the visits to the home by the representative of the director of the organisation are now being forwarded to the CSCI. These reports are detailed and cover all areas of the running of the home with clear action points. The electrical hard wiring certificate for the home recorded that the installation was unsatisfactory and detailed several areas that required attention. The Manager felt sure that the required repairs had been completed and agreed to forward evidence of this to the CSCI. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 22 Some staff at the home use their own cars to transport service users. The Manager said that staff had the appropriate insurance but evidence of this needs to be on site along with annual checks of staff driving licences. In-house checks on the fire equipment, emergency lighting and fire drills had been completed appropriately. There was evidence on site of the servicing of all equipment. COSHH substances were stored securely and not a risk to service users. As previously required exposed hot water pipes leading to the shower have been covered to reduce the risk of injury to service users. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 3 1 X 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Green Road, 26 Score 2 2 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000016884.V257166.R01.S.doc Version 5.0 Page 24 YES (ONE) 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 YA18YA6 Regulation 15 Requirement Care plans- Service user guidelines need to be dated to ensure they are current. Ensure plans detail the exact type of support required from staff. Where anxiety is recorded as a need then staff need guidance on how to reduce the risk of anxiety. Ensure that details of goals and actions agreed at review meetings are available and reflected in the care plan. A risk assessment must be completed for all areas of identified risk, for example holidays. Risk Assessments must cross reference with service users care plans. The Provider must review the transport arrangements to ensure that the Manager has adequate resources to enable service user activities away from the home to take place. The Manager must ensure that alternative meals are offered to service users, and a record kept. Timescale for action 30/12/05 2 YA6 15 30/12/05 3 YA9 12(1) 15 & 13(4) 30/12/05 4 YA13YA12 16(2) (mn) 30/12/05 5 YA17 16(2)(i) 15/12/05 Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 25 6 7 YA19 YA19 12(1)(a) 12(1)(a) 8 9 YA24 YA24 23(2) 23(2) 10 YA24 23(2) 11 YA33 18(1)(a) 12 YA42 13(4) 13 YA42 13(4) All service users must be supported to obtain a Health action plan. Effective monitoring of weight and bowel movements is required where this has been an identified need for service users. Flooring in the kitchen requires repair or replacement. (Unmet requirement from 30/1/05) Lounge chairs require repair or replacement. Adequate lighting must be provided in the downstairs hallway. A review of the premises is needed and plans developed to ensure the design is better suited to meeting the needs of the service users. The Manager must review the staff rotas to ensure staff do not work excessive hours and have appropriate rest time between shifts. The Manager must clarify if remedial works have been completed to electrical installations. Evidence to be forwarded to CSCI or arrangements made for the work to be done. Evidence must be available that staff have the appropriate insurance to use their own cars to transport service users. Staff driving licences must be checked annually. 30/01/06 15/12/05 30/01/06 30/01/06 30/01/06 30/12/05 18/11/05 30/12/05 Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 26 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 YA24 Good Practice Recommendations Additional communal space should be provided to include a conservatory and internal laundry. Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Green Road, 26 DS0000016884.V257166.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!