Inspection on 12/07/05 for 29 Byron Street

This inspection was carried out on 12th July 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 but made no statutory requirements on the home.

Other inspections for this house

29 Byron Street 11/08/07

29 Byron Street 01/08/06

29 Byron Street 23/02/06

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 Announced 12 July 2005 th 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 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 Stationary 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 E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 29 Byron Street Address West Bromwich, West Midlands, B71 1NP Telephone number Fax number Email 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 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 E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11 February 2005 Brief Description of the Service: 29 Bryon Street is a semi-detached property, which is rented from the Local Authority and is located in West Bromwich. The centre of town is within a two mile radius and there are local shops nearby. Public transport is good. The Home provides care for three service users who have a learning disability, two who are over the age of 65 years, one of whom also has a physical disability. The accommodation includes: a dining area, lounge, kitchen and toilet, on the ground floor. On the first floor there are three bedrooms, a sleeping in room, a bathroom and toilet. There is a Wessex vertical lift leading from the lounge area directly into the service user’s bedroom who has a physical disability. There is a ramp leading to the front door and back garden. There is off side parking on the road in front of the property. There is a large garden to the rear which is partly paved. The Home provides a range of in house and community based activities for residents. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted between the hours of 9.15 a.m. and 2.15 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: formal interviews with the manager, three support staff who were on duty and observations of care practices. There was also a tour of the premises. All residents were at home during the inspection. They were happy to speak with the inspector and either gave consent, or showed the inspector 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, the pre-inspection questionnaire, and an action plan submitted by the home following the last inspection. The inspector was made to feel very welcome and would like to thank service users and staff for their assistance and co-operation during the visit. What the service does well: The premises is decorated and furnished to a high standard providing a homely environment for residents to live. Staff support residents to make their own choices regarding the care that they receive. For example bedrooms are decorated and furnished according to their own tastes. Residents said that they could get up when they wished and could have a lie in. They can choose when they want to be alone or join in with others. On the day of the inspection some residents had chosen to sit outside in the sunshine and were joined by staff. There was lots of laughter and positive interaction between residents and staff. Another resident had chosen to stay inside and watch television. Residents were happy to talk about their favourite hobbies and past times. There is a strong emphasis on community based outings. For example, one resident during a two week period had been on at least ten outings. Another resident commented that staff take him to watch cricket matches at the weekends and that he goes shopping every week. Residents were looking forward to their annual holiday which is paid for by the organisation. This year they are going to Spain. Comments from residents included “I like it here they are very good and they help me quite a lot”. “I have a nice home and a nice church”. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 6 Staff were seen treating residents with dignity and respect. They showed sensitivity and patience when assisting residents with tasks such as moving and handling giving verbal reassurance in a kindly and professional manner. Staff support residents to maintain their health care and general well being. One social worker had stated during a review meeting that a resident had become much more independent since their arrival at Byron Street. There is a good care planning system so that staff have detailed guidelines in how to provide care and support to residents. Health care monitoring is of a high standard with all residents receiving regular health checks and as a result any issue identified is swiftly dealt with. There is a stable, experienced and exceptionally well trained staff group who are well supported by their manager. Staff are very dedicated and committed to providing a high quality service. Comments during interviews included “I love working here the residents and their needs are so important to me”. “I like the clients, they are all different and individual, it is like a close knit family”. There is very good practice in place to promote resident’s health, safety and welfare. 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 E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 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 standard(s) 1, 2, 3 and 5 The homes Statement of Purpose and Service User Guide are excellent providing residents and prospective service users with details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: Since the last inspection the statement of purpose has been amended as requested. In addition it has also been produced in a format for residents using a widget style system. There is a detailed pictorial service user guide. There have been no new service users admitted since the last inspection; there are no vacancies. As requested the manager has retrospectively written to the new resident who was admitted last year to confirm that upon assessment it was considered that the home could meet their needs as in compliance with the Care Homes Regulations 2001. There was ample evidence gathered to confirm that the can meet the assessed needs of service users and that staff collectively and individually have the skills to support them. A variation is still required for the current Registration as indicated at the last inspection. Each case file contains a statement of terms and conditions of occupancy and details are now contained therein of the actual fee levels charged per person. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 9 More details are required with regard to additional charges and what the basic fee includes. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 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 standard(s) 6, 7 and 9 There is a comprehensive care planning system so that staff are provided with guidelines in how to provide the exact level of care required by residents. Only slight expansion is needed in order to fully demonstrate how all of the needs of service users are met and ensuring that there are opportunities for residents to participate in review meetings. EVIDENCE: As required care plans have now been established for a new resident. Care plans are updated as and when residents’ needs change and there is a comprehensive assessment tool to assist in this process. Although there are regular evaluations of care plans carried out by support staff, some care plan review meetings have not taken place since May 2004. The National Minimum Standards require that care plan reviews must take place at least six monthly with service users and significant professionals and families where possible. There is a useful introductory summary to care plans which contains essential information as to how residents are supported with their personal care and how they communicate. All residents are self advocating and have some form of family involvement. The manager does not act as an appointee for any residents in respect of managing their finances. This is done by the Local Authority who funds their 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 11 placement. All residents have bank accounts and require differing levels of assistance from staff to support them in managing their personal allowances and benefits. Two of the three residents have ‘financial agreement’ sheet contained within their care plans which contain some information as to how they receive support. However as discussed with the manager these require expansion and ideally a care plan established to demonstrate the levels of support in place and the needs of individual residents in terms of money management. There are detailed risk assessments in place. As required at the last inspection a risk assessment with regard to a wheelchair user has been updated. The Inspector will provide more information regarding the latest advice from the Medicines and Healthcare products Regulatory Agency. One care plan demonstrates a need with regard to assistance with bathing and challenging behaviour for one service user; a corresponding risk assessment is required. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15 and 16 Staff support service users to achieve maximum independence through a variety of stimulating activities and community outings which reflects their own needs and preferences; as a result residents lead fulfilling and enriching lives. EVIDENCE: During the inspection residents spoke about their favourite hobbies and past times. Care plans contained information as to how residents participate in independent living skills such as laying the table and helping with vacuuming. Care plans also contained goals and objectives relating to family involvement and social inclusion. It is clear from interviews with residents and staff, and on examination of residents’ daily diaries that they enjoy a wide range of outings and activities which are community based. For example, case tracking for one resident confirmed that during a fourteen-day period they had enjoyed at least ten outings in the community. Residents always go on an annual holiday which is funded by the organisation as required by the National Minimum Standards. This year residents are going 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 13 to Spain and they spoke excitedly about the forthcoming holiday. One resident showed the inspector their personal spending money they were saving. Staff make very good efforts to support residents in maintaining their family links; they ensure residents are given some privacy when their relatives visit the home. Observations and interviews confirm that daily routines are not regimented and are user led. For example one resident stated that they liked to rise early but could have a lie in when they wished. Another resident is helped to get up a little later by staff according to their wishes. Residents can choose when to be alone or when to have the company of other residents. For example on the day a couple of the residents enjoyed sitting outside in the sunshine whilst another resident chose to stay in the lounge watching television. They can also choose to have a nap in the afternoon if they so wish. Residents also have televisions in their own bedrooms so that they can watch a programme of their own choosing. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 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 standard(s) 19 and 20 The 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: All care plans contain goals and objectives with regard to healthcare and screening. There are detailed records in respect of health care monitoring. For example residents receive monthly weight checks. All health care checks are up to date in respect of appointments for chiropody, ophthalmology and dental checks. The Manager has booked appointments for residents to receive an annual health check and medication review (in one case) from their General Practitioner. Residents will be booked to attend annual well person clinics. There is good liaison with the primary care team and district nurses also visit to monitor health care. Staff continue to strive to ensure that they monitor residents’ needs and access support. One resident has increased nutritional needs which are closely monitored. As requested mention of this has been included in the introductory care plan however slight further expansion is necessary, for example to describe how and when nutritional supplements are administered and the type of soft diet required (and any other strategies employed). It is 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 15 also suggested that the size of food portions are recorded as an extra aid to assist in monitoring. It is refreshing to see that the majority of residents do not receive any medication. Although medication is of a minimum, staff still follow good practice with regard to the control and administration of medication. For example there are good records kept in respect of receipt of medication. Medication Administration Record (MAR) sheets contain no gaps. Since the last inspection the manager has been able to obtain copies of reports from the visiting pharmacist. These identify no issues. Staff training is on-going. The medication policy has been amended but slight expansion is still necessary which has been discussed with the organisation at an inspection of another service. It is recommended that the administration of food supplements is recorded. As the resident does not receive any form of medication it is suggested that this is recorded in the daily diary system. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 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 standard(s) These standards were not assessed at this inspection. EVIDENCE: 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 and 30 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: All communal areas and residents’ individual bedrooms were seen (with their consent). The home was tidy and clean through out. The décor and furnishings reflect a homely and domestic type environment. All areas were bright and airy. Residents’ bedrooms are decorated to reflect their individual tastes and contain personal possessions such as photographs, pictures and ornaments. There are a range of aids and adaptations to aid independence such as a Wessex style vertical lift and portable hoist, transfer belts and pressure relieving equipment. There is a small domestic laundry which is located in an outbuilding. Staff feel that this meets the needs of residents. There is a domestic washing machine and dryer. The washing machine does not have a sluice cycle but this facility is not required. There is a sink which is used as a hand wash basin. There is no manual sluicing. There are only a couple of minor improvements necessary. For example the bathroom needs regrouting and there needs to be a supply of liquid soap and paper hand towels kept in the laundry. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 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. EVIDENCE: Staff are supportive of one another and work together as a team. They have detailed knowledge regarding their roles and the needs of service users. Training is a priority within the organisation and over 50 of the staff team are qualified to NVQ II or above which exceeds the National Minimum Standards. There has been no reduction in staffing levels since the last inspection. There are two staff on shift during the day time this sometimes includes the manager although he does have some supernumerary hours. A new member of staff has recently been recruited which will allow for more flexibility in rostering the hours. There are regular staff meetings at which important topics are discussed. It was pleasing to see that staff date and sign the minutes which have been taken as an indication that they have read them and agree to their content. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 19 There has been an improvement in the recruitment and selection procedures for new staff. For example all pre-employment checks were received prior to commencement of duties. Staff are undertaking induction and foundation training by an accredited learning disability awards framework provider. There was evidence that the new member of staff had been registered on this training programme. Added to this new staff receive a gradual induction from the manager which is comprehensive and thorough. It was pleasing to see that new staff are not rushed and overloaded with policies, procedures and care plans upon starting their employment. All staff have individual training profiles. There is a central staff training and development programme however dates need to be included of when training has either been undertaken or planned. The manager operates a good supervision system. From records sampled there was evidence that staff are receiving regular and structured supervision sessions. An annual appraisal system has been set up by the organisation although this is not fully implemented as amendments and alterations are anticipated to make the system simpler. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 41, 42 and 43 The management approach of the home creates an open, positive and inclusive atmosphere; as a result both service users and staff are enabled to air their views and affect the way in which the service is delivered. There is good practice followed by the manager to promote the health, safety and welfare of the service users and staff. EVIDENCE: Staff feel supported by the manager whom they feel that they can go to with any problems. As already stated there are regular staff meetings and one to one supervision sessions. Improvements have been made with regard to quality assurance. Pioneer Care have sent out excellent questionnaires to families, friends and stake holders in the community. Some feedback has already been received from families of service users at 29 Bryon Street. Feedback is still awaited from stakeholders. It was pleasing to see that the manager had already contacted families to discuss issues raised from completed questionnaires. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 21 Examination of a staff personnel file reveals that records required by the Care Homes Regulations 2001, Regulation 19(1)(b) regarding forms of identification are not all in place such as a photograph. A criminal record bureau (CRB) disclosure check was also missing. The Inspector had viewed these at the last announced inspection of the service and was not unduly concerned. However, CRB’s must either be held on the premises or details of the disclosure must be contained within individual staff files for reference. A full evaluation of staff mandatory training will be undertaken at the next inspection. During interviews staff gave details of what training they had recently undertaken which demonstrates that training is on-going. For example all staff have recently undertaken fire safety training but certificates are awaited. This is now being carried out on a bi-annual basis. Staff are now checking the smoke alarms on a more regular basis as required. The home was inspected by the fire safety officer on 2 June 2005. Issues identified have now been addressed with regard to bedroom doors. The manager is to contact the fire officer with regard to interlinking of the smoke detector in the lounge. Maintenance and service records were examined. These were found to be up to date and demonstrate good health and safety practice. For example, there is regular servicing of the portable hoist and passenger lift. All electrical and gas appliances have been tested. There is testing of water temperatures and also a recent bacterial analysis in respect of Legionella. There is good practice relating to food hygiene with regular testing of food, fridge and freezer temperatures. Foods are also stored correctly. Any additional items discussed during this inspection are contained within the Requirements section of this report. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 22 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 x 2 x 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 2 2 Standard No 11 12 13 14 15 16 17 3 3 4 3 3 x x Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 29 Byron Street Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 2 2 x 2 3 2 E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 23 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 3 Regulation 12(1)(a) Requirement To apply for a variation in Registration due to the decrease in adults who have a learning disability who are over the age of 65 years. (Previous timescale of 1/5/05 is not met). Ensure statement of conditions of residence are developed to meet standard 5.2 of the National Minimum Standards (i.e. to include specific room to be occupied by service user etc.). (Previous timescale of 1/11/03 is partly met). To ensure that the care plan is reviewed with the service user and involving other significant professionals and families where possible) at least every six months. To establish care plans to demonstrate how service users are assisted and supported to manage their own finances. To establish written risk assessments with regard to a service user who needs support with bathing and who may exhibit challenging behaviour as reflected in care plans. To establish a separate care plan Timescale for action 1/9/05 2. 5 5(1)(b) 1/11/05 3. 6 15(1) 1/11/05 4. 7 15(1) 1/11/05 5. 9 13(4)(c) 1/9/05 6. 19 12(1)(a) 1/9/05 Page 24 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 for a service user with increased nutritional needs detailing strategies which are in place for meeting these needs. For example, food supplements etc. (Previous timescale of 1/5/05 is partly met). To ensure that a nutritional screening and assessment is undertaken for the new service user admitted in July 2004. (Previous timescale of 1/5/05 is not met). To record size of food portions for service users with increased nutritional needs. The Home must review and expand medication policy to all areas of control and administration of medication. (Previous timescale of 1/10/03 is partly met). To continue to progress plans to ensure that all staff receive accredited training in the safe handling of medication. (Previous timescale of 1/11/03 is partly met). To regrout tiling in first floor bathroom. To carry out a written risk assessment with regard to clinical waste and infection control measures. (Previous timescale of 1/7/04 is not met). To ensure there is a supply of liquid soap and paper towels in the laundry area. To fully complete the central staff training and development programme with details of the dates of training undertaken and planned. (Previous timescale of 1/6/05 is not met). 7. 20 13(2) 1/11/05 8. 9. 27 30 23(2)(b) 13(3) 1/11/05 1/8/05 10. 35 18(1)(c) 1/11/05 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 25 11. 12. 13. 36 37 39 18(2) 18(1)(c) 24 14. 41 17(2) To introduce annual appraisals for all staff. (Previous timescale of 1/11/03 is partly met). To ensure that the Registered Manager is qualified to NVQ IV in care by 2005. To expand quality assurance systems to include feedback from all stakeholders (i.e. G.P.’s social workers etc.). (Previous timescale of 1/11/03 is partly met). To obtain and hold information 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. To ensure that all service users have an inventory of their personal belongings. To ensure that copies of the monthly reports from visits undertaken by the Owners representative are available on the premises and a copy forwarded to the Commission for Social Care Inspection on a more regular basis. To ensure that the reports contains information in sufficient detail as requried by the Care Homes Regulations. 1/11/05 31/12/05 1/11/05 1/11/05 15. 43 26 1/9/05 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. Refer to Standard 20 43 Good Practice Recommendations To establish a suitable method for recording the administration of food supplements. To ensure that the Employer’s Liability certificate includes the name and address of the Home. E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 26 29 Byron Street 3. 29 Byron Street E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 Page 27 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen B62 8BR 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 E55 S4826 Byron Street V231936 120705 Stg4.doc Version 1.40 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. 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