Inspection on 01/12/06 for 47-49 All Saints Road

This inspection was carried out on 1st December 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

47-49 All Saints Road 18/09/08

47-49 All Saints Road 19/03/08

47-49 All Saints Road 20/03/06

47-49 All Saints Road 28/07/05

47-49 All Saints Road 11/03/05

47-49 All Saints Road 13/01/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 47-49 All Saints Road 47-49 All Saints Road Bromsgrove Worcestershire B61 0AQ Lead Inspector Julian Mason Unannounced Inspection 1st December 2006 10:40 47-49 All Saints Road DS0000061835.V312550.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 47-49 All Saints Road DS0000061835.V312550.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. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 47-49 All Saints Road Address 47-49 All Saints Road Bromsgrove Worcestershire B61 0AQ 01527 579520 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) Worcestershire Mental Health Partnership NHS Trust Mrs Amanda Deborah Jeffries Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 47-49 All Saints Road is a traditional two storey detached house in a residential street within a mile of Bromsgrove town centre. Each of the five service users has their own bedroom, individually decorated and furnished, with a shared lounge, dining area and kitchen. Local shops, public transport, the Mental Health Resource Centre and voluntary sector day centres are nearby. The home aims to provide a domestic environment promoting independence and dignity. Service users receive care and support to live as ordinary a life as possible in the community. The registered manager at the home is Amanda Jeffries. She was registered as the manager of the home in January 2005. The registered provider is the Worcestershire Mental Health Partnership NHS Trust. The responsible individual is Ms Ann Bennington. The Trust has been the registered provider since July 2004. Before this date, they were the staffing provider only. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to the home. The inspection visit started at 10.40am and finished late afternoon on the same day. One inspector visited the home and observed some of the events and routines of the day. Several residents files were examined and a range of records were sampled. A member of staff gave a tour of the building and the inspector participated in the lunchtime meal. The inspector met a number of staff and residents who were in the home at the time of the visit. The manager had completed a pre inspection questionnaire, which gave some additional information about the home. Five “have your say about…” questionnaires were completed by residents and one “relatives / visitors comment card” was returned. What the service does well: What has improved since the last inspection? What they could do better: The home’s care plan format needs to include the stated aims and aspirations of individual residents. All residents care plans should be reviewed within required timescales. The reviews should be systematic and focus on the progress made in relation to the identified needs of each resident. Where nonprescription drugs are administered by staff to residents appropriate administration records must be completed. All staff must attend vulnerable adult protection training. The service needs to ensure that all staff achieves the required social care qualification that matches their role and responsibilities. Core training for all staff must be completed within appropriate timescales. Staff should also be provided with ongoing training and development opportunities in the area of mental health services. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An appropriate assessment of needs is carried out for all new residents. EVIDENCE: An assessment of needs is completed for all new residents. The home only accommodates those people whose needs can be met by the service. Consideration is also given to new referrals in relation to their compatibility with the existing resident group. The home’s assessment process for prospective service users is based on a range of information relating to their background, needs, likes and dislikes. Information is gathered from a range of sources including other relevant professionals, family members and previous carers. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans need to be reviewed regularly and include the goals and aspirations of residents. Review meetings should be used to assess how well the service is meeting identified needs. Residents are encouraged to make choices and decisions about their daily lives and routines. EVIDENCE: Each resident has an individual plan of care that identifies specific needs in relation to care and support. Each resident has a named keyworker who carries some responsibility for ensuring that the home meets the resident’s assessed needs. The home’s care plan format listed the areas identified and allowed care staff to make written entries in relation to the progress being made. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 10 Some residents had complex and challenging needs and the care plan included guidelines for staff to promote the effective management of behaviour. These guidelines included preventative measures and appropriate responses to circumstances of increased risk. The plans also highlighted specific support in relation to individual health needs and disabilities and how residents are supported to access services to promote continuing good health and wellbeing. The care plans did not include residents own aspirations and goals, although individual case files included this information it was not included in the care plan format. It was difficult to know how the home was supporting individual residents to achieve their own expressed aims and objectives. The home was reviewing individual plans of care but the information did not reflect who attended the meetings. It was not clear if significant professionals, family, friends and advocates had been invited. The process was not systematic in relation to reviewing individual care plans. Reviews did not provide a summary of progress against individual areas of identified need. In some cases, residents were making good progress in some areas but these achievements and successes were not reflected in the review meeting documents. Reviews were not taking place within required timescales. Where residents are not in control of their own finances the review process should also be used to confirm that the arrangements continue to be appropriate. Staff respected and supported residents rights to make decisions about their daily lives and routines. The home demonstrated a commitment to appropriate levels of care, support and protection, and a residents need to pursue their own choices and preferences. Known and potential risks to residents and the community were assessed and recorded in individual risk assessments. Assessments were reviewed and updated according to new circumstances and needs. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are involved in opportunities for personal development and growth but a wider range and choice should be promoted. Staff support a range of activities in and outside the home. The home helps residents stay in touch with their friends and relatives. The arrangements for mealtimes are relaxed and homely. EVIDENCE: Residents attend various educational and /or occupational settings on a full or part-time basis. The routines are well established and staff support attendance and engagement at various locations and settings. For the days that residents are only attending their day placements on a part time basis, they are at the home. It was not clear to what extent care staff helped residents find out about and take-up opportunities for further 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 12 education, distance learning and vocational, literacy and numeracy training on these days. Also, it was not clear how the home helped residents find out about and take-up work / training opportunities or alternative day activities. Residents are supported and encouraged to access local facilities and services. Staff in the home have pursued a policy of community access and integration. Many of the venues and activities are longstanding and well established. Staff need to guard against limiting the range and access of leisure activities and venues. Providing and promoting new information in relation to accessing community facilities and leisure activities should be an on-going process with regular consultation with residents and advocates about new opportunities and experiences. Friends and family contact is encouraged and supported within the home, there are no restrictions and visitors are welcome at any time. The daily routines of the home are organised to promote independence and choice. Residents are able to come and go as they please and have free movement around the home that is consistent with group living arrangements. Care practices and daily routines are flexible and dependant on pre-arranged appointments, residents health and wellbeing. Residents are being encouraged and supported to develop their domestic skills through written rehabilitation schedules. Individual schedules outline domestic tasks to be completed by each resident with the support and encouragement of care staff. Food is purchased locally and staff prepare meals according to the planned weekly menu which residents are involved in. Residents are encouraged and supported to help staff with the food shopping. Mealtimes are flexible and drinks and snacks are available throughout the day. The mealtime routines are relaxed and unhurried with residents being involved in preparation and clearing away routines. Individual food preferences are known and considered when meals are planned and prepared, alternatives are provided if needed. Records demonstrated a reasonably varied diet is being offered. The home’s compliments and complaints book included many positive comments from residents about the food. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and support is delivered with sensitivity and respect. The health and wellbeing needs of residents are being met. Medication is administered safely, but non-prescription drugs must be appropriately recorded. EVIDENCE: Staff are sensitive and flexible in relation to personal support and care. Privacy and independence is promoted to ensure residents maintain control over their lives that is consistent with individual circumstances. Care records are being written in an appropriately respectful way and care files include details of how residents prefer to be supported with any personal care. Out of the five resident questionnaires that were retuned, three said that staff always treat you well and two said that this usually happens.The staff demonstrated a respected attitude towards residents and they were observed to interact in a pleasant and supportive manner. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 14 All residents are registered with community health services and systems are in place to ensure that appointments and visits are monitored and recorded. Staff provide encouragement and support for residents to ensure that they access appropriate services to maintain good health and wellbeing. Specific health checks are also carried out to monitor any adverse effects prescribed medication may have on residents health. The home has written policies and practice procedures in place regarding the administration of medication. Staff are administering a range of medication from prescription drugs to household medication. The manager of the home monitors the administration records and staff have recently received refresher training. The medication returns book demonstrated that items no longer needed or used were returned to the pharmacist. The home uses a specific and well-used system for the administration of medication. Pre-printed administration record sheets are also supplied to support the system being used. Records demonstrated that prescription drugs are being recorded at the point of receipt, administration and disposal. The records confirmed that practice standards for the dispensing of prescribed medication are met. The home did not carry any household medication but an entry made in a resident’s therapeutic contact notes indicated that Paracetomol had been given on a specific date. The medication records did not reflect this particular administrative event. If staff in the home administer non-prescription drugs appropriate administration records must be completed. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are systems in place to support residents or their representatives to raise concerns or complaints. The home has appropriate policies and procedures in place to protect residents but staff need to receive training in the protection of vulnerable adults. EVIDENCE: The home has appropriate policies and procedures in place to support staff in keeping residents safe. Arrangements are in place for residents to make a complaint. The home promotes and uses the complaints procedure that is detailed in the residents handbook about the service. The home’s internal complaints record demonstrated that no complaints from residents had been made since the last inspection. The returned questionnaires indicated that all five residents knew how to make a complaint. An adult protection policy is in place, which reflects the local multi-agency vulnerable adult guidelines. No adult protection issues have been reported since the last inspection. Staff have not received any training in relation to the protection of vulnerable adults. The manager needs to ensure that the staff team are given opportunities to learn, understand and be more aware of issues regarding safety and protection. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are being provided with a clean and well-maintained environment that is homely and comfortably furnished. EVIDENCE: The home is located in a residential area of Bromsgrove close to local amenities with access to the bus route into the town centre. A tour of the home was completed. All Saints Road consists of a kitchen, two lounges, individual bedrooms, laundry and sufficient bathrooms and toilets to meet the needs of all residents. The communal rooms are comfortable and well furnished and provide adequate space for shared activities and communal living. There is an enclosed garden to the rear of the property that is well maintained and has easy access. The home has a repairs and maintenance book in place so the home can monitor the general upkeep of the building, fixtures and fittings. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 17 The premises were clean and tidy and there were no unpleasant odours or smells. Policies and procedures for infection control were in place and some staff have completed training in this area. Paper towels and liquid soap were available in the communal bathrooms. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are being supported and cared for by an established and consistent team of staff. More training and development opportunities are needed to improve core skills and knowledge. The vetting of staff is completed to the required standards. EVIDENCE: The home’s staffing structure is clear in terms of individual roles and responsibilities. The staff team at All Saints Road is well established and provides consistent care and support for residents. At night, one residential care worker sleeps-in and is on call if needed. The staffing rotas indicated that a number of staff were on duty throughout the day and then one member of staff being available from late afternoon onwards. The rota did not necessarily provide for the potential for residents to arrange and attend ad-hoc or spontaneous evening activities and events with the support of staff. There was some flexibility in shift patterns when planned and known events occurred. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 19 None of the staff team have left the service since the last inspection and no new staff have been employed. Any staff absences are covered from the home’s own staffing resources. The recruitment and selection processes follow an established procedure that includes a range of vetting checks that match the required standards. Staff personnel files are appropriately stored and secured in the manager’s office Out of the team of five support staff three have an appropriate NVQ qualification in social care and the manager continues to study for the registered manager’s award. All staff need to complete social care training that is commensurate with their role and responsibilities so as to achieve the appropriate levels of qualification within the team. An annual assessment of the staff team’s overall training needs is completed and a training plan is drawn up to meet those needs. Staff have undertaken some training since the last inspection such as fire safety, behaviour management and the administration of medication. The manager has also received specific training related to her role and responsibilities. Some core training is still outstanding for a number of staff despite the home being aware of the deficits. Staff have received very little on-going training and development in relation to specific areas of mental health needs or awareness. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a consistent level of care. Managers need to achieve an appropriate qualification that is matched to individual roles and responsibilities. Quality assurance systems need to be developed further to ensure care and support is improved and maintained according to residents needs. Appropriate standards of health and safety are being maintained. EVIDENCE: The management arrangements in the home remain unchanged with the registered manager being supported by a deputy manager. Both managers have relevant experience and are qualified mental health nurses. The registered manager is continuing to work towards the appropriate social care 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 21 qualification for the role. The deputy manager should also undertake the necessary training to achieve the appropriate level of qualification for the role. The home is still in the process of developing its quality assurance systems. Work has begun with mapping the services that are provide against national minimum standards. Residents of the home have recently completed questionnaires about what they think of the service and a questionnaire from a non-resident had also been completed. There was no evidence that the home had acted or responded to the information in the questionnaires. The recent consultation process was not part of any systematic cycle of consultation, planning, action and review. The home did not have an annual development plan; it was difficult to determine if any improvements had been made to the service based on any feedback from consultation or auditing processes. The home’s policies and procedures cover the necessary areas in relation to the health, safety and welfare of residents and staff. Fire drills are taking place with the frequency required. Testing of emergency lighting, fire alarms and fire fighting equipment is also taking place within appropriate timescales. Staff attend fire safety training in May this year. All required utility checks and installations are tested and / or serviced with in required timescales. Electrical appliance safety checks have also been completed. The home has comprehensive environmental risk assessment processes and procedures in place but no recent assessments have been completed. The home needs to ensure that risk assessment documents highlight any environmental hazards and detail how risks will be minimised. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA39 Regulation 24 Requirement Effective quality assurance and quality monitoring systems must be in place to measure success in achieving the aims, objectives and statement of purpose of the home as outlined in Standard 39. Previous timescales - 31/07/06 not met. The home’s care plan format must include the stated aims, aspirations and goals of individual residents. The plan must detail how the home will support residents to achieve their objectives. Timescale for action 31/03/07 2 YA6 15 31/03/07 3 YA6 15 The care plan review process 31/03/07 must include a systematic review of a residents identified needs [involving significant professionals, family, friends and advocates as agreed with individual residents]. Care plan reviews must take place at the request of a resident or at least every six months. Staff who administer nonDS0000061835.V312550.R01.S.doc 4 YA6 15 31/03/07 5 YA20 13 28/02/07 Version 5.2 Page 24 47-49 All Saints Road prescription drugs to residents must complete the appropriate administration of medication records. 6 7 YA23 YA32 13 12 All staff must complete vulnerable adult training. Staff in the home must achieve the necessary NVQ social care qualification that matches their individual role and responsibilities. Each staff member has an individual training and development assessment / plan that identifies core training needs and specific areas of professional development that is consistent with occupational roles in mental health services. Training and development is linked to the home’s service aims and to service users needs and individual plans. 9 YA42 23 Environmental risk assessments must be completed. 31/07/07 31/03/07 31/03/07 8 YA35 18 31/03/07 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 YA33 Good Practice Recommendations The staff rota should be flexible enough to ensure that residents can be supported to participate in evening activities and events that are not necessarily planned in advance. Review meeting minutes should include the names of DS0000061835.V312550.R01.S.doc Version 5.2 Page 25 2 YA6 47-49 All Saints Road those people, who were invited, attended and gave apologies for non-attendance. 3 YA6 Where residents are not in control of their own finances the review process should also be used to confirm that the current arrangements continue to be appropriate. 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 47-49 All Saints Road DS0000061835.V312550.R01.S.doc Version 5.2 Page 27 - 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!