Inspection on 07/11/05 for 34 Walsall Street

This inspection was carried out on 7th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 42 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

34 Walsall Street 20/01/09

34 Walsall Street 05/02/08

34 Walsall Street 18/07/07

34 Walsall Street 05/07/06

34 Walsall Street 23/05/05

34 Walsall Street 18/01/05

34 Walsall Street 13/09/04

34 Walsall Street 27/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 34 Walsall Street Willenhall Walsall West Midlands WV13 2ER Lead Inspector Lesley Webb Unannounced Inspection 7th November 2005 09:40 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 34 Walsall Street Address Willenhall Walsall West Midlands WV13 2ER 01902 632211 01902 421941 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) Swan Village Care Services Limited Care Home 5 Category(ies) of Learning disability (3) registration, with number of places 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service users with physical disability aged 18-65 years to be admitted. 23 May 2005. Date of last inspection Brief Description of the Service: 34 Walsall Street is a registered care home for up to five adults, owned by Swan Village Care Services Limited. The home is a large, detached house set it its own grounds situated in a residential area of Willenhall. The local town centre is within easy access, just a short walk away. The home is also situated on bus routes, enabling service users to access the town centres of Willenhall and Wolverhampton. The building consists of five single bedrooms, two of which are located on the ground floor with en-suite shower facilities, lounge, separate dining room, kitchen and laundry. There are also two bathing facilities located on the first floor of the building near to the remainder of bedrooms. On the third floor there is a large room that is not accessed by service users, this is used as a storage facility for the home and the proprietors of Swan Village Care Services Limited. The main aim of 34 Walsall Street is to enable people with learning difficulties to have an Ordinary life. Staff at the home aim to achieve this by encouraging and working with service users to be fully integrated into the community in which they live and to take part in activities according to their individual needs, abilities and interests. 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived at 9.40am and stayed until 5.30pm. Time was spent talking to service users, interviewing staff, looking at records and observing care practices before giving feedback about the inspection to the acting manager. This is the second inspection to take place at the home this year and therefore both this report and the one published in May should be read when looking at information regarding the home. Since the last inspection the home has spent time without a registered manager. Ms Afia Walker was appointed as manager of the home 3 weeks ago and is completing her probationary period, after which an application for registration will be submitted. By the end of the visit the inspector was satisfied that generally care provided to people living at the home is satisfactory. Due to the new manager being in post for such a short time and the amount of requirements needing attention 2 further monitoring visits have been arranged to check progress with these. The inspector would like to thank service users and staff for their co-operation and assistance during the visit, where she was made to feel very welcome. What the service does well: The inspector found lots of evidence that shows the home is flexible when arranging for new service users to visit the home. These visits can include overnight stays, joining in activities and meals and meeting other people who live at the home. Staff have a very good understanding of their roles and how they support service users who are ill. As one member of staff explained, “we must respect service users choices, keep them company and make as comfortable as possible”. As in the previous inspection staff were observed spending time talking to service users and assisting them with their care while respecting their rights and responsibilities. For example one service user did not want staff to assist when making a drink while another requested the company of a member of staff when they went to the shop. Staff at the home are also very good at promoting service users rights to confidentiality. Everyone was able to give examples of how they do this and give details of the homes policies on confidentiality. 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 6 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. 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. The home’s statement of purpose, assessment processes and introductory visits to the home are adequate, enabling prospective service users to make choices about where they live. The home is not meeting all the needs of people who live there, if allowed to continue this could affect their quality of life. The home’s terms and conditions of residency issued to service users ensure they are aware of their rights and responsibilities. EVIDENCE: The home has a statement of purpose and service users guide that are displayed at the entrance to the home. Although giving comprehensive information these are not available in a format suitable for their intended users. The inspector was informed that this was going to be addressed, with the home producing this document in video format. All files sampled contained community care assessments completed by the relevant placing authorities. In addition to these the home completes it own pre-admission assessments. Upon inspection of these the inspector instructed that this should be amended to include an assessment for compatibility with others already living at the home. This is required due to the home not only having to be sure it can meet the needs of a prospective service user but also to demonstrate that they are considering the needs of people already living a 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 9 the home. The inspector is very concerned that the home is not considering the needs of people already living at the home with regards to smoking. A new service user has moved to the home who smokes with everyone else already living there being non-smokers. The home does not have a separate smoking area and the inspector witnessed the new service user smoking in the same room as non-smoking service users. Due to some of the people living at the home having very limited abilities to make decisions and form choices the inspector instructed that a separate room (such as the addition of a conservatory) be allocated for the person who smokes if their placement is to continue. The inspector reiterated that the home has a responsibility with regards to passive smoking and instructed that legal advice be sought regarding this and a policy implemented. Previous requirements relating to communication training and staff working within a learning disability award framework remain unmet. These need to be addressed in order that the home can demonstrate staff have the skills to meet the needs of people living at the home. The inspector found an abundance of evidence through looking at records and discussions with service users and staff that the home meets the cultural requirements of service users (as documented in their care plans). Further work is required to demonstrate the religious needs of individuals are met. For example 1 service users care plan and activity timetable stated that they must attend a temple at least twice a week but no records were available that validated that this occurs. The home has a written policy regarding introductory visits to the home that follows guidance set out in the national minimum standards. Discussions with staff confirmed that visits are arranged based on the needs of individuals. For example one person said, “people can come for tea visits, half and full day visits. They can also stay overnight, join in activities, meet other service users and staff”. Contracts/terms and conditions of residency were seen for all but one service user (the one service user without this documentation is still in the 3 month probationary period). These were found to follow guidance as set out in standard 5 of the national minimum standards for younger adults. 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 and 10. Care planning remains poor resulting in service users being at risk of not having their needs met in full. Some risk assessment processes are very poor, placing service users and staff at risk of harm. Information is stored correctly in this home, ensuring service users rights to confidentiality are maintained. EVIDENCE: No progress has been made to ensure care plans are in place that detail how all aspects of social, personal and health needs of service users are to be met. The new manager recognises that this must be addressed and assured work would be completed to meet these requirements. All files sampled contained risk assessments that generally corresponded with service users care plans. The inspector was concerned however that detailed risk assessments had not been completed for a service user who displays challenging behaviours. A large amount of incident forms were found to be 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 11 completed by staff but these had not been analysed with management systems put into place. The inspector was also concerned that many incidents have occurred during the night when only one member of staff is on duty. This places that staff member and other service users at risk. The inspector also instructed the home that it must notify CSCI via a regulation 37 notification of every incident relating to this particularly service user as previously this had not occurred. It was also noted by the inspector that many staff working at the home require training in challenging behaviours. Staff did however demonstrate some knowledge of risk assessment processes. For example one person explained, “everyone is an individual and this should be reflected in the risk assessment”. The home has policies and procedures on confidentiality and data protection. When looking at these the inspector found that only 2 staff who work at the home having signed to state they have read and understood. All staff that were interviewed were able to explain their roles and responsibilities in relation to promoting service users confidentiality as well as demonstrating knowledge of the homes policy on confidentiality. For example one person stated, “Unless someone is at risk from harming themselves we must respect their rights to confidentiality. Information must never be taken outside of the home. You can be suspended or sacked if you do this”. 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14 and 16. Generally care planning provides staff with adequate information in order that they can support service users to develop personally. Improvements in the recording of activities must be made to demonstrate that the home provides daily variations and subjects of interest for the people living there. Staff’s excellent knowledge of resident’s rights and responsibilities ensures people living at the home can exercise choice and control over their lives. EVIDENCE: All files sampled contained care plans to develop independent living skills, however further work is still required to implement care plans for all aspects of social and communication needs (this remains outstanding from the previous inspection). As previously mentioned in standard 3 some service users at the home are not being supported to fulfil their spiritual needs. The acting 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 13 manager recognises that improvements are required and agreed this would be given priority. Each person living at the home has an activity plan with staff completing activity evaluation sheets once activities are completed. When looking at these the inspector found that either the plans were not always being followed or staff were not completing evaluation sheets. The inspector could also find little evidence of activity preferences raised in service user meetings being carried out. The home has a written policy relating to service users holidays in which it contributes £300 per year, however the policy does not state payment details for staff that accompany service users. The inspector was concerned after talking to staff that they only received payment for 7.5 hours per day when they are responsible for service users for 24 hours a day. If the service users were at home the building would be staffed over a 24-hour period, as this is what the relevant placing authorities are funding and therefore the same care package should apply when on holiday. Also the inspector could only find evidence that 2 of the people living at the home having been on holiday this year. Practices observed throughout the inspection demonstrated that the daily routines and house rules generally promote independence and freedom of movement. Since the last inspection the home has removed all locks on the kitchen cupboards that were previously restricting service users access to products. Records and discussions with staff confirm that service users are offered keys to the front door and their bedrooms and risk assessments completed where this choice is not given due to safety reasons. 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21. The home attempts to ensure service users wishes with regards to illness and death are respected. EVIDENCE: Although not assessed it was noted by the inspector that all previous requirements relating to the health needs of service users have now been met. Half of the files sampled contained service users and/or their family’s wishes concerning funeral arrangements and belongings after death. Those that were in place were very detailed and corresponded to people’s cultural needs. Although none of the staff that were interviewed have yet had to support someone who is very ill or dying they all demonstrated knowledge in this area. For example one person said, “you must try to comfort the person, keep them company if that is what they wish. Its also important to keep the family informed”. 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 15 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): Standards assessed at previous inspection. EVIDENCE: 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 16 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): 29. Generally the standard of the environment within this home is good, providing residents with an attractive and homely place to live. EVIDENCE: Since the last inspection many requirements relating to the environment have been met. These include new carpet and paintwork in the lounge, a new oven and garden furniture and part of the driveway tarmac. The home has a condition of registration in place whereby it cannot admit anyone with a physical disability due to the layout of the building. There is however one person living at the home who moved in prior to this condition being put in place. Records and discussions with staff confirmed that an assessment by a qualified person had been completed for this service users wheelchair but not for other equipment that might be necessary for this person to aid mobility around the building. 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 17 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): 31 and 36. Staff have good understanding of their roles and responsibilities ensuring service users receive the appropriate care and support. Support systems for staff must improve to ensure they can carry out their responsibilities effectively. EVIDENCE: All staff that were interviewed demonstrated knowledge of their roles and how aspects of these support the people living at the home. For example one person stated, “its my role to give service users any assistance they need when doing tasks, to maintain their confidence. To make sure they get the best care possible, to become as independent as possible”. In addition to this all staff files sampled contained job descriptions that complimented the aims and objectives of the home and the needs of service users. Previous requirements relating to training and staffing ratios remain unmet. The inspector instructed that these should be actioned urgently in order that staff and service users are safeguarded. None of the staff have received at least 6 formal supervision sessions (3 being the average). The inspector recognises that there has been no manager at the home for several months and that this has impacted upon staff receiving supervision. It was therefore pleasing to find that in the 3 weeks since the 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 18 new manager has been in post she has implemented an annual appraisal for everyone. 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 19 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 and 41. The lack of management since the last inspection has affected the overall quality of service provided to people living at the home. Generally records are adequately maintained protecting and promoting service users rights. EVIDENCE: Ms Afia Walker has been in post as manager for 3 weeks. Previous to this she worked as a senior support worker at another home owned by Swan Village Care Services. Ms Walker is currently completing the NVQ level 4 after which she will enrol on the Registered Managers Award. CSCI has been formally notified that an application for registration will be submitted once Ms Walker has completed her 3-month probationary period. Staff that were interviewed stated that the atmosphere in the home is relaxed. Everyone that was interviewed confirmed that the time spent without a permanent manager had been a little difficult but praise was given to the 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 20 organisations service co-ordinator for the additional support she had given during this time. The home has a comprehensive set of policies and procedures that are available to staff to read at any time. When looking at these the inspector found that only 2 of the staff working at the home have signed to say they have read these. The importance of policies and procedures was reiterated by one member of staff who informed the inspector, “they are there for a reason. Without them you would not know what you should be doing, what your role is and the guidelines around this”. Generally records in the home were found to be well maintained and stored in line with relevant legislation. It was however noted that no regulation 37 notifications had been sent to CSCI for incidents relating to a service user (as previously mentioned in standard 9). 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 21 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 2 2 2 3 3 Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 2 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x 2 x LIFESTYLES Standard No Score 11 3 12 x 13 2 14 2 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 2 x 2 2 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 34 Walsall Street Score x x 2 3 Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 2 2 2 DS0000020850.V264759.R01.S.doc Version 5.0 Page 22 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 2 Standard YA1 YA2 Regulation 4,5 14 Requirement The service user guide must be available in a format suitable for its intended readers The homes pre-admission document must include an assessment for compatibility with others already living at the home The home must be able to demonstrate it can meet the needs of smoking and nonsmoking service users. This must include: A separate smoking area away from non smoking service users Seeking legal advice regarding passive smoking and the homes responsibilities to protect nonsmoking service users Implementing smoking policies and procedures Seeking the views of permanent service users and their representatives e.g. social workers with regards to people who smoke moving into the 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 23 Timescale for action 31/01/06 31/12/05 3 YA3 12 21/11/05 home 4 YA3 16(3) The home must be able to demonstrate that the religious needs of service users are being met All residents must have six monthly multi-disciplinary review meetings to review their care plans – Requirement originally made May 2005. The home must develop service user care plans in order that they clearly detail the primary care needs (as listed in Standard 2) – Requirement originally made May 2005. The home must be able to demonstrate that service users are involved in monthly key worker meetings – Requirement originally made May 2005. Decisions made in response to resident’s requests and agreed at residents meetings must be carried through or reasons for not doing so must be documented – Requirement originally made May 2005. The home must involve service users in the day-to-day running of the home, and development and review of its policies and procedures – Requirement originally made May 2005. The home must be able to demonstrate that service users are involved in the recruitment and selection of new staff – Requirement originally made May 2005. Risk must be appropriately managed for the new service user who has moved to the home. This must include: Detailed risk assessments being 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 24 31/01/06 5 YA6 15 31/12/05 6 YA6 15 31/12/05 7 YA6 15 31/12/05 8 YA7 12(2) 31/12/05 9 YA8 12(2) 31/12/05 10 YA8 12(2) 31/12/05 11 YA9 13(4) 11/11/05 completed for challenging behaviours Incident forms being completed every time there is an occurrence of challenging behaviour Incident forms being analysed on a monthly basis and management action taken including the review of risk assessments Reassessment of the staffing ratios during the night with evidence forwarded to CSCI if these are not altered demonstrating how risk has been minimised Notifying CSCI via a regulation 37 notification every time there is an incident of challenging behaviour 12 YA9 13(4) All staff must undertake challenging behaviour training appropriate to the needs of the new service user The home must ensure transport is available for wheelchair users to access the community, activities and further education establishments – Part met. Requirement originally made May 2005. Activity plans must be followed and the reasons documented if this does not occur 31/01/06 13 YA13 16(2) 31/12/05 14 YA14 16(2) 31/12/05 15 YA14 16(2) Evaluation sheets must be completed for all activities The home must seek legal advice 31/12/05 in relation to employment law with regards to the payment of staff when escorting service users on holiday. This DS0000020850.V264759.R01.S.doc Version 5.0 Page 25 34 Walsall Street information must be forwarded to CSCI The home must implement a policy regarding the payment of staff when escorting service users on holiday (including payment for meals and activities) 16 17 YA14 YA20 16(2) 13(2) All service users must be offered a annual holiday or the equivalent in day trips Risk assessments must be completed that demonstrate if service users are able to self medicate and what support is needed if any – Part met. Requirement originally made May 2005. A risk assessment must be completed for the medication practices for the respite service user – Requirement originally made May 2005. Respite mediation must be handled according to the requirements of the Medicines Act 1968 and following guidelines from the Royal Pharmaceutical Society of Great Britain – Requirement originally made May 2005. The home must implement a written policy that details what service users must contribute out of their personal allowances towards Takeaway meals – Requirement originally made May 2005. The shower in room 2 must be usable – Requirement originally made May 2005. An assessment by a qualified person must be arranged for aids and adaptations for the service user with physical disabilities 31/12/05 31/12/05 18 YA20 13(2) 31/12/05 19 YA20 13(2) 31/12/05 20 YA23 10(1) 31/12/05 21 22 YA26 YA29 16(1) 16(1) 31/12/05 31/01/06 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 26 23 YA32 18(1) 24 YA32 18(1) 25 YA33 18(1) 26 YA33 18(1) 27 YA33 18(1) 28 YA35 18(1) 29 YA35 18(1) All staff must undertake communication training relevant to meeting service users needs – Requirement originally made January 2004. All staff must hold a care NVQ 2 or 3 or be working to obtain one by an agreed date – Part met. Requirement originally made May 2005. A minimum of three staff must be on duty during the hours of 7am and 9pm, seven days per week, with addition staff when the respite bed is used – Requirement originally made May 2005. The numbers and skill mix of staff on duty must ensure the following activities are carried out effectively: - uninterrupted work with individuals, administration, organisation and communication, day to day running of the home and management of emergencies – Requirement originally made May 2005. The staff rotas must be expanded and include details of when service users are out of the home and time spent on domestic duties by staff – Requirement originally made May 2005. Certificates must be maintained at the home for staff that have undertaken equal opportunities training – Requirement originally made May 2005. A training needs assessment must be carried out for the staff team as a whole, and an impact assessment of all staff development undertaken to identify the benefits for service users – Requirement originally made January DS0000020850.V264759.R01.S.doc 31/12/05 31/01/06 07/11/05 07/11/05 31/12/05 31/12/05 31/12/05 34 Walsall Street Version 5.0 Page 27 2005. 30 YA35 18(1) The home must be able to demonstrate that staff use Learning Disability Award Framework (LDAF) accredited training – Requirement originally made May 2005. Staffs individual training assessments must be updated regularly – Requirement originally made May 2005. All staff must receive at least 6 supervision sessions per year An application to register a permanent, appropriately qualified and experienced manager must be submitted to CSCI – Requirement originally made May 2005. Regular staff meeting must occur with minutes maintained An internal audit of the quality assurance system must take place at least annually – Requirement originally made January 2005. An annual development plan for the home must be implemented – Requirement originally made January 2005. The results of service user, families and stakeholders in the community surveys and questionnaires must be published and made available to all interested parties including the CSCI – Requirement originally made January 2005. All staff must read and sign the homes policies and procedures CSCI must be notified of any event as listed in Regulation 37 of the Care Homes Regulations 2001 All staff must hold up to date food hygiene, first aid, moving DS0000020850.V264759.R01.S.doc 31/01/06 31 YA35 18(1) 31/01/06 32 33 YA36 YA37 18(2) 9 31/03/06 20/01/06 34 35 YA38 YA39 18(2) 24 31/12/05 31/12/05 36 YA39 24 31/12/05 37 YA39 24 31/12/05 38 39 YA40 YA41 Schedules 1,4 37 31/01/06 07/11/06 40 YA42 13(3-6) 31/01/06 34 Walsall Street Version 5.0 Page 28 41 YA42 13(3-6) 42 YA43 25 and handling and infection control certificates, with records maintained at the home for inspection – Part met. Requirement originally made January 2005. All staff must undertake two fire 31/01/06 training sessions per year, with certificates maintained within the home – Part met. Requirement originally made May 2005. A financial plan for the home 31/12/05 must be available for inspection – Requirement originally made March 2003. 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 YA13 YA3 Good Practice Recommendations It is recommended that the home purchase its own transport that meets the needs of the people living at the home That a conservatory be built for service users who smoke 34 Walsall Street DS0000020850.V264759.R01.S.doc Version 5.0 Page 29 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. 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