Inspection on 01/08/06 for 29 Byron Street

This inspection was carried out on 1st August 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

29 Byron Street 11/08/07

29 Byron Street 23/02/06

29 Byron Street 12/07/05

29 Byron Street 11/02/05

29 Byron Street 05/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 29 Byron Street West Bromwich West Midlands B71 1NP Lead Inspector Jayne Fisher Unannounced Inspection 1st August 2006 09:30 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 29 Byron Street Address West Bromwich West Midlands B71 1NP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 553 2443 NONE Pioneer Care Limited Mr Paul Jones Care Home 3 Category(ies) of Learning disability over 65 years of age (3), registration, with number Physical disability (1) of places 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include 3 service users whose ages may range between 60 and 65 years of age and above at any one time. 23 February 2006 Date of last inspection Brief Description of the Service: 29 Bryon Street is a semi-detached property, leased from the Local Authority, and operated as a Home by Pioneer Care Ltd. Set in a quiet residential area of West Bromwich, two miles from the Town centre, it is close to local facilities and well served by public transport. The Home provides care and accommodation for up to three adults who have a learning disability. Two of the Residents are over the age of 65 years, one of whom also has a physical disability. Accommodation comprises a dining area, lounge, kitchen, and toilet on the ground floor, with three bedrooms, ‘a sleeping-in room’, a bathroom and toilet on the first floor. There is a Wessex vertical lift leading from the lounge area directly into the bedroom of the Resident who has a physical disability. There is parking on the road in front of the property and there is a large, partly paved garden to the rear with access to both areas facilitated by ramps. The Home provides a range of in house and community based activities for Residents. A statement of purpose and service user guide are available to inform residents of their entitlements. Information regarding fee levels was provided on 12 July 2006 which are between £583.50 and £905.91 per week. There are additional charges for toiletries and hairdressing. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 09:30 a.m. and 14:30 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: interviews with the manager and two staff. There were no feedback comment cards received from residents or relatives. All residents were at home during the inspection. They were happy to speak with the inspector and gave consent for the inspector to view their bedrooms. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of visits undertaken by the owner’s representative and a pre-inspection questionnaire. All residents’ care was case tracked by reading and assessing care documents, observing interactions and by talking to staff and chatting to residents. Two meal times were observed. Only a brief tour of the premises was undertaken as the home was undergoing a major refurbishment at the time of this visit. What the service does well: Staff continue to provide residents with support and care which is very much geared towards their individual needs. For example, on arrival at 9:30 a.m. two residents were up and had received their breakfast, another resident was having a lie–in and got up later at a time of his own choosing. Residents are enabled to be as independent as possible and take responsibility for making their own choices and decision making. They enjoy a range of activities and community based outings which meet their individual preferences and needs. Residents were looking forward to their annual holiday in Spain which is paid for by the organisation. There is good monitoring of residents’ health so that any potential complications are quickly dealt with. Residents are provided with a varied and well balanced diet. There is a complaints procedure so that residents can raise their concerns. Regular meetings are held for residents and staff so that they can air their views and be consulted about any aspects of the running of the home. The premises is decorated and furnished to a good standard providing a homely environment for residents to live. Residents are supported by a stable, enthusiastic and dedicated manager and staff team. Training is given a high priority. During the visit residents looked content and relaxed in their surroundings and indicated that they were happy living at their home. There was lots of positive 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 6 interaction observed throughout the visit. Despite the on-going major refurbishment, staff were ensuring that there was minimal disruption to residents’ lives and the atmosphere was calm and cheerful. 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. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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): 2 and 5 The overall outcome for this group of standards is judged to be good. Residents are provided with information regarding the services available. There is an holistic assessment process so that new residents can be assured their individual needs will be measured and met. Only slight improvements are needed to the terms and conditions of occupancy for residents to be informed about all of the charges they may incur. EVIDENCE: There is a statement of purpose as seen at previous visits which covers all of the required subjects. There is also a new service user ‘handbook’. On examination this includes a pictorial service user guide and other important information. A copy has been provided by the organisation for each resident. There are no vacancies at Bryon Street and no new residents have been admitted since 2004. There is a comprehensive assessment tool which can be used for assessing prospective new residents should a vacancy occur including an independent living skills task assessment entitled ‘my step towards a future’. The resident who was the latest to be admitted to the home looked happy and at ease in his surroundings. During interviews staff confirmed that he had settled very well into the home and got on well with the other residents. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 9 On examination all residents’ case files were seen to contain a copy of terms and conditions of occupancy. These contain the majority of elements required by the National Minimum Standards, for example they include details of the fee charged, bedroom occupied and are signed by the registered manager, advocate or resident. There is only one minor exception: there are no details of any additional charges which are incurred and these should be included in the contract as well as details of what fees do cover, for example, the cost of an annual holiday. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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 and 9 The overall outcome for this group of standards is judged to be adequate. All residents have a range of care plans and risk assessments in place, although more detailed written guidelines for staff to follow would enhance current systems further and reflect more accurately the high level of support and care given to residents by staff. EVIDENCE: Care plans and risk assessments cover a range of subjects but are basic in content. The manager states that this is because it was intended to keep the format as simple as possible for ease of use. It is acknowledged that the small and stable staff team are fully familiar with residents’ needs as demonstrated through interviews however, some expansion would be beneficial especially for new staff. For example, whilst one resident has a risk assessment in place with regard to pressure area care there is no corresponding care plan, and the risk assessment does not include all equipment provided to relieve pressure. Another resident has a risk assessment in place with regard to occasional verbal challenging behaviour; control measures state that ‘staff are to be aware how to approach X’, however there are no written guidelines regarding 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 11 the ‘approach’ used, (although during interviews the manager and staff gave clear responses). There are risk assessments in place regarding bathing but no mention of safe water temperatures. Control measures identified include that staff be present to ‘assist’ X out of the bath’, but there are no details as to what type of assistance is required. One resident requires extra nutritional support and a further page has been added to include guidelines for staff as there is no further space to write on the existing care plan proforma. This gave extra details as required but did not include types of food stuffs that during interviews staff stated had to be avoided. These were added by the key worker. Activities are included in care planning but need to be updated for example one resident no longer chooses to go to church. There are details of how residents are supported with finances contained within risk assessments but no separate care plans. It was pleasing to find that a key worker who was interviewed was familiar with the care planning system. Care plans are regularly reviewed (monthly) and the manager has introduced a system to ensure residents, relatives and social workers are invited to attend at least six monthly review meetings. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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 and 17 The overall outcome for this group of standards is judged to be good. Staff support service users to achieve maximum independence through a variety of stimulating activities and community outings which reflect their own needs and preferences; as a result residents lead fulfilling and enriching lives. The meals provided to residents are good offering both choice variety and catering for special dietary needs. EVIDENCE: Staff encourage residents to maintain their independence; during the visit residents were seen taking their own cups into the kitchen for washing up and helping staff. One resident asked the inspector if they would like a drink. None of the residents choose to attend any formal day care provision. They chatted about their favourite leisure pursuits. For example, one resident stated that he liked watching his favourite programmes on television and likes to go to his bedroom to listen to his favourite music which is Country and Western. One resident is supported to go and watch local cricket matches by staff and remains a devoted church goer, and talked about the social as well as 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 13 the spiritual benefits of visiting his church. Two residents talked happily about their forthcoming annual holiday to Spain. The third resident is unable to go on holiday due to health reasons. It was inspiring to see that staff had recently landscaped the garden to the rear of the premises themselves in order to provide the resident with a more pleasant area for sitting in the sun or shade. During interviews residents discussed their preferred community based outings. For example, one resident said that he liked visiting markets, another said that he went to West Bromwich every week to collect his benefits. Each resident has a daily diary in which staff record their activities. Case tracking revealed that residents undertake a number of activities within the home and in the community. Staff continue to support residents in maintaining family links. For example, the manager takes one resident to see his family at his request which is usually twice a year. Daily routines are flexible according to the individual preferences of residents. For example on arrival at 9.30 a.m. one resident was still in bed, preferring to have a lie in. During the visit staff were seen to spend time talking to residents. Residents confirmed during interviews that they could spend time alone in their own bedrooms. Two meal times were observed. These were relaxed and unhurried. Residents had the choice of eating at the dining table or in the lounge. One resident has a soft diet due to eating and swallowing difficulties and a care plan has been expanded to include guidelines for staff. During interviews residents confirmed that they enjoyed the meals provided and stated their preferences which on examination of daily food records confirmed that they were offered their favourite foods. There is no set menu plan as residents choose meals on a daily basis which promotes choice and individuality. Nutritional screening tools are in place which are reviewed at least annually. The administration of nutritional supplements are fully recorded as is good practice. It was pleasing to see that staff encourage healthy eating with fresh vegetables and produce. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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 The overall outcome for this group of standards is judged to be good. The personal care and health needs of service users are well met and careful monitoring helps identify any potential complications at an early stage ensuring service users’ receive the treatment they require. EVIDENCE: During interviews residents indicated that they were happy living at the home. One resident stated “I like it here, they are very good to me”. Staff were seen to be caring in their approach to residents and maximising their dignity in how they provided support with moving and handling. During interviews staff were knowledgeable with regard to residents’ like and dislikes for example explaining how one resident takes particular pride in his appearance and likes to receive compliments. There is a range of technical aids and equipment to support one resident with mobility difficulties which include a Wessex style vertical lift, portable hoist, adjustable bed and various lifting aids. There is also a pressure relieving mattress and cushion. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 15 A diary system assists staff with monitoring routine health care appointments. Residents attend regular dental checks, eye tests and well person clinics. There are monthly weight checks for two residents. During interviews residents confirmed that they had access to health care services; one resident stated that he had been seen by the district nurses recently who were happy with his progress. There is only one minor improvement needed. Two residents receive regular chiropody appointments. A third has not been able to access these on a regular basis and the manager has therefore resorted to cutting his toenails in the intervening periods between appointments. As discussed regular chiropody must be accessed for this resident unless training and approval is obtained by the chiropodist/podiatrist. Since the last visit a medication review has been undertaken by the doctor with regard to the one resident who was in receipt of regular medication. As a result medication has now been withdrawn and no residents are in receipt of medication. However staff still receive training in the safe handling of medicines which is an excellent initiative. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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 overall outcome for this group of standards is judged to be good. There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon. There are procedures in place to safeguard service users from abuse. EVIDENCE: There have been no complaints received about the service during the last twelve months. There is a comprehensive complaints procedure which has also been produced in a pictorial format (a copy of which has been included in the new service user handbook). During interview a key worker gave good examples of how she would support residents if they wished to raise concerns. All staff have received training in vulnerable adult abuse with the exception of one new member of staff. During interviews staff gave appropriate responses to how they would deal with any potential incidents of abuse. As required at previous inspections the manager has obtained copies of relevant documents such as the Local Authority vulnerable adult abuse procedures. No residents exhibit challenging behaviour or require any physical interventions. There are procedures in place with regard to service users’ financial affairs. The manager states that he does not act as appointee for any residents although is countersignatory for one resident. Residents need varying levels of support to manage their finances. There are personal expenditure sheets to record all financial transactions with double signatures obtained from staff. Petty cash vouchers and receipts are obtained for larger cash purchases. Residents receive smaller sums of money to spend according to their wishes although they require support from staff. Records are entered on to the 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 17 personal expenditure sheet of when they receive this money although receipts and petty cash voucher are not deemed necessary. As discussed with the manager care plans need to be established to explain how residents are supported in managing their finances (to accompany the current risk assessments which are in place). 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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 and 30 These standards were not fully assessed at this visit. EVIDENCE: On the day of visit the home was in the middle of a major refurbishment therefore a full tour of the premises was not possible. The Landlord is undertaking a refurbishment of the kitchen and bathroom, electrical re-wiring and replacement of the central heating system. The manager states that the smoke alarm system will also been interlinked. Careful planning and liaison by the manager with the contractors has taken place so that there is minimal disruption to residents which is commendable. For example a temporary kitchen has been installed in the dining room whilst works are undertaken. A tour of residents’ bedrooms were undertaken with their consent and communal areas were also viewed. All parts of the home were seen to be clean and tidy and free from offensive odours. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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): 32, 33, 34, 35 and 36 The overall outcome for this group of standards is judged to be good. Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve and maintain their quality of life. The arrangements for induction of staff are good with staff demonstrating a clear understanding of their roles. Recruitment and selection procedures offer protection to residents although slight improvement is needed to further enhance systems in place. EVIDENCE: The home employs five support workers two of whom are qualified to NVQ II or above. Staff who were interviewed confirmed that they were encouraged to undertake training and a new member of staff stated that he hoped to enrol on a NVQ course in the autumn. There is a stable staff group. The majority of staff have either worked at the home or with the same employer for over five years. On examination of the duty rota there are at least two support staff on duty per daytime shift. On occasion there are three staff on duty which the manager states enables staff to spend time individually with residents this sometimes includes the manager, although he does have some supernumerary hours. There are regular staff 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 20 meetings. During interviews staff stated that they enjoyed working and worked well together as a team. The manager has recruited one new member of staff since the last visit. Examination of the personnel file confirms that good recruitment and selection procedures were followed. The member of staff was appointed on a (Protection of Vulnerable Adult - POVAFirst) check and as required the manager informed the Commission for Social Care Inspection and completed a written risk assessment. As required by the Care Homes Regulations 2001, the member of staff was supervised at all times whilst a criminal record bureau (CRB) disclosure check was awaited. There are only a couple of items requiring attention. There was an incomplete employment history declared by the member of staff on the application form. The manager stated that he had tried to get a full employment history but had been unsuccessful however this is a legal requirement and all records of discussions must be recorded including attempts at validation. For instance, the member of staff had previously worked for the organisation for two and a half years but had not included this on his application form. He had also worked for three months for a previous employer but had not put this on his form. During interview he also indicated that he had worked at another care establishment some years previously. There was no copy of a recent photograph or form of identification held on the premises. It was pleasing to see that the new member of staff had commenced induction training which had been provided by an accredited learning disability awards framework (LDAF) provider. There was a central training matrix which was supplemented by a training needs assessment carried out by the manager earlier in the year to identify any training shortfalls. All staff have individual training and assessment profiles in place in their personnel files. On examination there is regular supervision of staff by the manager with records maintained. A previous appraisal system was abandoned by the organisation and a new system is currently being introduced as stated by the manager. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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): 37, 39 and 42 The overall outcome for this group of standards is judged to be good. Residents benefit from a well run home with the manager and staff demonstrating an awareness of their roles and responsibilities. The manager ensures so far as is reasonably practicable the health, safety and welfare of residents and staff. EVIDENCE: The manager has now completed his NVQ in both care and management and continues to demonstrate a dedicated and caring approach to his role. For example, he often works on six consecutive days but feels that this does not impact upon his ability to work efficiently and is of benefit to the residents. Mr. Jones’s management approach is conducive to promoting an open and positive atmosphere for both residents and staff. The organisation is continually improving and developing the quality assurance systems. For example, the manager states that recently staff and a service user from another care establishment have visited and assisted residents to 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 22 complete satisfaction questionnaires. Copies of these were contained within their service user guide and examination confirmed that they were happy with the support provided by staff at the home. The manager states that the provider has also sought feedback from stakeholders and relatives although the outcome of this consultation process has not yet been received by the manager or an annual development plan established based upon the monitoring exercise and including all other arrangements for review of the service. There continues to be regular visits by the operations services manager with reports completed which are forwarded to the CSCI. There are regular service user meetings and it was pleasing to see that residents had been consulted about the current refurbishment of the premises. A sample maintenance and service records were examined. These were found to be largely up to date with only a couple of exceptions. There are monthly or bi monthly fire safety evacuation drills as is good practice. At the same time as the drills staff carry out testing of the smoke alarms. This must be carried out weekly. There is a water temperature log but staff are failing to test the water temperature of wash hand basins in residents’ bedrooms. There is up to date servicing of the wheelchair used by one resident but no records of the regular health and safety checks undertaken by staff. There is mandatory training for staff. Examination of the training records which was cross referenced with a sample of training certificates confirmed that staff have undertaken all of the required disciplines in statutory training which is an excellent achievement. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 2 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 2 X 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 24 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 YA5 Regulation 5(1)(b) Timescale for action To ensure that the statement of 01/12/06 conditions of residence are developed to meet all of the requirements of the National Minimum Standards 5.2 for example including any details of additional charges. To review and expand existing 01/12/06 care plans to ensure that all aspects of personal and social support and health care needs are included in greater detail for example, pressure area care and how residents are supported to manage their finances. To review and expand existing 01/12/06 risk assessments and ensuring that they include all control measures to minimize risks to residents. To ensure that all service users 01/11/06 receive regular chiropody treatment. To ensure that a full employment 01/12/06 history is obtained for all new staff with written records maintained. To obtain and hold information 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 25 Requirement 2. YA6 15(1) 3. YA9 13(4)(c) 4. YA19 12(1)(a) 5. YA34 13(6) 6. YA36 18(2) and documents (on the premises), in respect of persons carrying on, managing or working at a care home as listed in Schedule 4 of the Care Home Regulations 2001. For example a copy of a recent photograph and copy of identification for all new staff. Ongoing work, to develop and introduce a staff appraisal system, suitable for this Staff group, must be completed. To continue to progress plans to expand quality assurance systems to include feedback from all stakeholders (i.e. G.P.’s social workers etc.). 01/12/06 7. YA39 24 01/12/06 8. YA42 13(4)(a) To produce an annual development plan based on a systematic cycle of planningaction-review, reflectng aims and outcomes for service users. To ensure that there is weekly 01/11/06 testing of the smoke alarm system. To ensure that water temperatures from wash hand basins in residents’ bedroom are tested and recorded. 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 YA32 Good Practice Recommendations That the home continues to work towards meeting Sector skills workforce targets of 50 of care staff having achieved an NVQ level 2 or above. DS0000004826.V306482.R01.S.doc Version 5.2 Page 26 29 Byron Street 2. YA37 3. YA42 It is recommended that the home is enabled to access and use e-mail and web site facilities to assist with communication and researching current good practice and guidance. It is recommended that staff record the health and safety checks undertaken with regard to the wheelchair. 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 29 Byron Street DS0000004826.V306482.R01.S.doc Version 5.2 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!