Inspection on 10/10/06 for 290 Newton Road

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

290 Newton Road 05/03/09

290 Newton Road 31/01/06

290 Newton Road 14/07/05

290 Newton Road 09/03/05

290 Newton Road 24/11/04

290 Newton Road 20/02/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 290 Newton Road 290 Newton Road Great Barr Birmingham B43 6QU Lead Inspector Deirdre Nash Unannounced Inspection 10th October 2006 2.30pm 290 Newton Road DS0000043211.V314477.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 290 Newton Road DS0000043211.V314477.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. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 290 Newton Road Address 290 Newton Road Great Barr Birmingham B43 6QU 0121 357 7517 0121 357 8417 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) enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31 January 2006 Brief Description of the Service: 290 Newton Road is a large detached dwelling adapted to be a care home in 2003. The home caters for up to seven people with a Learning Disability, and additional emotional and psychological needs within the autistic spectrum disorder range. The home offers personal care and support to a group of individuals with a range of complex needs and strives to promote ordinary living principles and social inclusion. Staffing levels reflect the level of support required for the individuals accommodated. The home is situated on a very busy dual carriageway near to local shops, post office, and pubs etc. There is a pedestrian subway crossing. The home is accessible by public transport and offers limited off road parking, which is shared with the adjacent supported living project. The premises offer a small yard and recreational space at the rear of the property. The accommodation is spread over three levels. Service users bedrooms are located on the ground and first floor. There is a passenger lift. Office space and staff rooms are on the second floor. The unit has seven single bedrooms, all of which offer en-suite toilet and hand-basin, with one ground floor room also providing an en-suite shower. Communal space includes a lounge and dining area and a `quiet` lounge. Kitchen facilities are domestic in size and there is a separate laundry, which offers commercial equipment. Social and recreational pursuits are provided for the occupants and the home also has its own people carrier vehicle, which is used to transport residents to appointments and for outings etc. A fee level for 2006/7 is not available. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We looked at all of the information that we have received about this home since it was last inspected. Comments cards were sent out to relatives to get their views about it but none were completed and returned to us. We sent question cards to residents. None were returned to us. We will improve the way that we try to find out residents and relatives views in advance of an inspection in future. The Manager completed a questionnaire and returned it to us in early October bringing us up to date with facts and figures about the home. The Inspector called at the home without notice mid afternoon, spoke with the manager, the deputy, two members of staff, met three residents and spoke at some length to one, looked around the home and looked at records. The care of a sample of two residents was followed in this way to see if the home is providing a service that meets the national minimum standards. Time spent with residents and observing staff going about their work with residents was limited because of the unsettling affect that such a presence in their home has on some residents. Residents did show signs of general well being. What the service does well: The home provides one to one care and attention for its residents. Managers and staff get to know the residents well and work closely with their families. The home makes good use of the independent advocacy organisation that the Provider company commissions to help speak up for residents who cant do so easily for themselves. This resulted for example, in one female resident getting the ground floor room with the en suite bathroom to give her more privacy than she could have using communal bathrooms on the first floor. Each resident has an assessment of their needs by their social services department and the home produces an individual plan for their care that closely follows this. The home is commended for the quality of these care plans. Residents can choose and plan their meals and staff do encourage healthy eating. The home makes sure that residents get routine as well as specialist health care. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 6 Residents are helped to keep busy and have an activities programme as part of their care plan. This includes sessions at a local college for some. They are also encouraged to contribute to the day to day running of the house. The home is clean and fresh. Bedrooms reflect the personality of the individual and are used by residents throughout the day as they please. One resident said “Look! This is the key to my room”. What has improved since the last inspection? What they could do better: The manager is not registered with us and the home must have a registered manager. Many doors in the house including the street and garden door, kitchen and bathrooms have a digital lock that residents cannot operate. These restrictions on freedom must be accounted for in writing for each individual affected by them otherwise the home is operating as an unlicensed Secure Unit. Staff files do not contain all of the information that is required by law to show that they are suitable to work with vulnerable people. If this information is kept at head office this must be agreed with us so we can go and check it. The home has been told about this before and it must improve or we will exercise our responsibility to take enforcement action for the protection of residents. Residents and their relatives or representatives have no way of knowing how much care and accommodation costs at the home, who pays for what and what the extras are. We have told the home to make this clear in a statement of terms and conditions for each resident. The two communal bathrooms are stark and institutional. We recommend that they are made more homely and comfortable. Staff work twelve-hour shifts. This is a long time to spend giving total attention to one person among seven who can be very challenging and staff do look tired by 6pm. We have asked the home to reconsider this arrangement for everyone’s safety. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 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. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 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 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 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, 2, 3, 5 The outcome for this group is good. This judgement has been reached using available evidence including a visit to the service. Information about the home is available and the home has a full assessment of needs for each resident. Residents live in a home that can meet their needs. EVIDENCE: The home has made no recent admissions. The statement of purpose is available in the hallway and each care file looked contained a service user guide. Key worker staff files show that specialist training for meeting particular needs of residents is limited but other records support the comments of the manager and show that fifteen places have been booked on two specialist short courses in November 2006. Resident’s files showed no written contract or terms and conditions for care and accommodation. This means that rights and responsibilities are not clearly set out for residents, their relatives or representatives. Current residents are funded by a variety of social services departments so it should be possible to show the fees and the extras. The home has been advised to improve on this as a matter of good practice. 290 Newton Road DS0000043211.V314477.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, 8, 9, The outcome for this group is good. This judgement has been reached using available evidence including a visit to the service. The home produces plans of care that follow the aims of the community care plan for the individual, are underpinned by risk assessment and in a format assessable to residents and have the potential to show how and where individuals can make their own decisions. Resident’s needs, goals and aspirations are reflected in their plans of care. EVIDENCE: Two residents care files were looked at, a man and a women. Both contained clear and comprehensive plans of care that closely mirrored what their social work care manager had agreed the home would provide for the individual in their community care plan. Systematic review was seen. Plans that involve some risk are cross-referenced to written risk assessment and management plans. Comments from key worker staff showed that they have read these plans. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 11 Although there was some evidence in the daily records for these two residents, there is room for the home to improve how it shows that residents are making decisions and agreeing to each area of the plan and risk management. The manager reports that the new format of these care plans has been tried with these residents and that each of them were able to follow it and understand what it referred to. This is very positive work. The home is commended for it 290 Newton Road DS0000043211.V314477.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, 17 The outcome for this group is good. This judgement has been reached using available evidence including a visit to the service. The home shows that service users are getting access to a reasonable range of activity and occupation and that family relationships are supported. Service users have a lifestyle suited to their age. EVIDENCE: Community care plans for the two individuals in the tracking sample included specific aims for each resident for occupation and education, access to leisure and reducing social isolation. These are both very young people. The service user plan for each addressed those aims. Interests and potential activities are listed. An activity planner template is in place for each week for each person and they are completed by staff for morning, afternoon and evening. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 13 This record also shows where the individual has declined what was planned and offered something else. Daily records looked at support the weekly record of events. These plans and records also show the regular involvement of relatives. Activities and occupation for one resident ranged from baking and housework to bike riding and attendance at a computer skills course. Although comments from staff suggest that the bike riding is not currently happening. Residents have 1:1 support each day for twelve hours. The fridge contained fresh vegetables juice, milk and salad and fresh fruit is in a bowl in the kitchen. One resident spoken to confirmed that he gets what he likes to eat and chooses and plans what is bought. A joke between him and his care worker showed that staff do gently persuade him towards a share of healthy food each week. Photo cards were seen in the kitchen to help decision making about food and meals. 290 Newton Road DS0000043211.V314477.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, 20 The outcome for this group is good. This judgement has been reached using available evidence including a visit to the service. Personal and health care is detailed and reviewed in individual care plans and staff consult those plans. Service users receive personal support in the way that they prefer and require. EVIDENCE: A range of records was seen for health care in both the files of residents in the tracking sample. Staff comments show that they follow the written plan when giving personal care. One resident spoken to confirmed that staff help him to have a bath ‘properly’. Daily records support observations that residents can run their days as they wish and that routines are flexible. One resident was seen eating his evening meal in the quiet room because he prefers to. The plan for one individual contained physical intervention instructions and safe restraint directions particular to her. Another showed behavioural incidents record charts. In neither file did these dominate care and support plans however. This balance was reflected in the attitudes of staff spoken to. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 15 Records show that residents receive routine as well as specialist health care and each have a health action plan. One residents weight record shows that he lost one stone over a month in the summer although started to re gain some thereafter. There was no evidence that this was planned or had been evaluated and accounted for. The manager has been asked to look into it. All records should be brought together at review of the residents care plan and used to assess it effectiveness or inform changes. A sample of medication records was looked at and there were no gaps or omissions. Medication was seen to be properly and securely stored and the manager reports that the named staff who administer it are all currently undertaking a four-module safe handling of medicines course. Staff questioned are aware of the company policy and procedure to follow in the event of an error. Records showed PRN (as and when appropriate) procedures for individuals. One resident’s file contained a record of disagreement between his relative, the home and his GP about the use of medication to control anxiety and some behaviour. 290 Newton Road DS0000043211.V314477.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, 23 The outcome for this group is good. This judgement has been reached using available evidence including a visit to the service. The home has a well-publicised complaint procedure and staff are clear about their duty to report poor practice and concerns about service users well being. Good policies and procedure protect residents. EVIDENCE: The manager reports that the home has received one complaint since the last inspection, this was about how an adult protection matter was handled and the Provider company investigated it. There is no record of this at the home and there should be, the records are at head office. A requirement is made to keep a record of all complaints made or concerns raised in the home and available for inspection. Contact that the home has had with us over recent weeks shows that protection of residents is taken seriously, allegations are reported out to other bodies and the manager supported by the Provider company takes responsible action thereafter. One member of staff has been dismissed and referred by the manager to the List held by the secretary of State. Another allegation is currently under investigation. Directions were seen in care plans looked at to protect individuals from particular self-harming behaviours. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 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, 25, 26, 27, 28, 30 The outcome for this group is adequate. This judgement has been reached using available evidence including a visit to the service. The home is generally well decorated, well maintained and kept clean and fresh. However all exterior and many interior doors have locks that residents cannot operate. Residents are confined without any one being accountable for it. EVIDENCE: Most of the house was toured and one service user in the tracking sample agreed to show the Inspector his bedroom. His room, like most of the house is generally well decorated and comfortable. This bedroom had football club curtains and rug and contained a computer and music centre. The resident showed the Inspector the key to his room that he carries with him. The back yard is dominated by a huge fire escape staircase encased in corrugated metal. There is no grass or flowers in the tubs but there is some garden furniture and sports equipment. Residents were seen talking to staff in the yard. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 18 The communal bathrooms are sparse and uncomfortable, one contains a metal locker with mops and buckets spilling out of it and there is a hole in the artificial ceiling and no curtain or blind on the window. The light pull string was dirty and so was the broken swing bin. The manager reports that the hole in the ceiling is current maintenance work in progress. It is recommended that these bathrooms are made more comfortable. When everyone was at home the main communal room appeared crowded with up to seven residents and seven care workers. The manager should monitor these times of day against incident and accident records. There are digital locks on the kitchen, bathrooms, the front door in side and out and the inside of the back doors that residents cannot operate. There is no risk assessment in care files to justify any of these. The home cannot lock residents in without even accounting for it as a duty of care decision agreed by all parties. This is operating a Secure Unit and the home is not licensed to run as such an establishment. A requirement is made to review the necessity for every lock and account for any and every lock considered necessary through a multi disciplinary agreement, in writing for each resident and to review each decision regularly. 290 Newton Road DS0000043211.V314477.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, 36 The outcome for this group is adequate. This judgement has been reached using available evidence including a visit to the service. There are gaps in important information about staff and although regular supervision takes place insufficient induction and training has been provided. Service users are not benefiting from a professional approach to their care. EVIDENCE: The home operates on a one to one staffing level between 8am and 8pm. This level of staffing was seen on the day of this unannounced visit. Referred to above staff work 12-hour shifts and some looked tired by 6pm. These are very challenging service users and there are seven of them living in the same house and sharing the same communal space. It is recommended that the Provider organisation reviews this shift pattern and considers shortening shift lengths for the safety of residents and staff. Three personnel files were inspected, two key workers to the residents in the tracking sample and the most recent recruit to the staff team. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 20 There were some gaps in the information required to demonstrate that staff are fit to work with vulnerable people. One worker has only one acceptable reference; the other four are open testimonials. Another recently appointed worker, new to care work has no reference that addresses probity and good character. The provider company must acquire full references from prospective employees. Original CRB Disclosure certificates are not kept on these files although POVA (protection of vulnerable adults List) First checks were there. The home must follow the CSCI guidance on the retention and storage of these documents and the manager was referred to our website. This was raised at the last inspection when a requirement was made and there has not been sufficient improvement. The Commission will exercise its responsibility to take enforcement action for the protection of residents if the home continues to fail to properly comply with this regulation. There was a brief induction checklist on each file. This is not sufficient particularly for workers new to care work. Workers must undertake the Skills For Care Induction Programme of competence. This was raised at the last inspection. The manager was referred to the Skills for Care Website. There was no evidence that staff have or are undertaking the Learning Disability Award Framework (LDAF) although a number are enrolled on NVQ in Health and Social Care Programmes. The LDAF would better equip staff to work with the current residents of the home. This was raised at the last inspection. It is recommended that new staff go through a ‘Skills for Care Induction’ and through the LDAF. The training profile of one key worker did not reflect the assessed needs of the key resident. For example there was no communication training although the resident uses MAKATON and no manual handling training although the resident has some mobility difficulties and mobility risk assessment. A requirement was made to produce or update a training needs assessment at the last inspection. None of the files looked at showed that staff have undertaken any training in autism. Records show that this training has been booked for most staff to attend in November this year and this is positive progress. Supervision records confirmed staff comment that they receive regular one to one sessions with a manager. 290 Newton Road DS0000043211.V314477.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, 38, 40, 41, 42 The outcome for this group is good. This judgement has been reached using available evidence including a visit to the service. The home is well run with a clear internal and external management structure and managers have good contact with service users and their relatives. Service users live in a home that is run in their best interests. EVIDENCE: The manager is not registered with us and a requirement is made to submit an application. There is a deputy manager and two team leaders. Staff spoken to confirm that the group works as a team and that the interests of residents are put first in the home. Records show that fire safety systems are regularly tested and the passenger lift is regularly inspected and serviced. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 22 Certificates were seen for induction health and safety training for staff but referred to above other statutory training has not been undertaken such as manual handling and a requirement is made to improve this for the safety of residents and staff. A sample of a written policy document inspected supported what staff described as correct procedures for that area of practice. There is no evidence of any structured quality assurance system for the services provided by the home although the manager reports that the Provider organisation has commissioned some work on this now. The views of service users and other stakeholders should be regularly sought and the service subject to a continuous plan of improvement. Records show that fire safety equipment and installations are regularly tested and serviced and fire drills take place. The lift has been regularly inspected and serviced. The home has men and women living in the house and the Provider has employed men and women on the care staff team. The Directors of the Provider Company have recently changed but the Responsible Individual and senior managers remain the same. 290 Newton Road DS0000043211.V314477.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 3 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 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 3 3 X 3 X 2 3 2 3 X 290 Newton Road DS0000043211.V314477.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 YA22 Regulation 17 Requirement The registered person must ensure that every concern or complaint is put on record and kept in the home. The registered person must ensure that the necessity for and access through every lock in the home is reviewed. Any and every lock that any resident cannot negotiate must remain in place only with service users agreement and /or as a result of a multi disciplinary professional decision. It must be put in writing for each resident and reviewed for each resident regularly. The Registered person must ensure that all information and proofs required to establish the fitness of employees to work with vulnerable people are obtained and kept and made available for inspection in line with latest CSCI guidelines on retention and storage of this information. Timescale for action 25/11/06 2 YA24 17 31/12/06 3 YA34 19,18 30/11/06 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 25 Audit all staff files and set about obtaining any missing information. Part met from last inspection compliance date set at 31/05/06 4 YA35 The registered person must 31/12/06 ensure that the training needs assessment for the staff team and the development plan for the home addresses the specific needs of residents, skills for Care Induction and statutory and vocational training. (Previous timescales of 30/11/05 & 31/12/05 & 30/06/06 partly met) 8 The registered person must ensure that an application is made to the CSCI by a suitable person to register as manager of the home. 25/11/06 5 YA37 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 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 YA4 Good Practice Recommendations Provide a written contract/statement of terms for care and accommodation in the home including the fees and the extras for each resident. The home needs to expand on its evidence to show how service users are making individual choices, and to be able to show when decisions are made by staff on behalf of the service users and why. Consult all health care running records during the review of a care plan to make sure that the care plan is addressing any changes in health or well being. Copies of prescriptions obtained for service users medication should also be held. It is also recommended that arrangements be made to manage controlled drugs should the situation arise within the home. Improve the comfort of the communal bathrooms. Review the length of staff shifts; consider shortening them from 12 hours. 2 YA7 3 YA19 4 YA20 5 6 YA27 YA33 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 27 7 9 YA35 YA39 Adopt the Learning Disability Award Framework for training all new care staff. Develop a system for regular review of the quality of the service including consulting residents, relatives and other ‘stakeholder’ in the home and send a summary to the CSCI. 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 290 Newton Road DS0000043211.V314477.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!