Inspection on 26/01/06 for 5 Wellington Street

This inspection was carried out on 26th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 Wellington Street 03/04/07

5 Wellington Street 17/06/05

5 Wellington Street 11/11/04

5 Wellington Street 07/06/04

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 5 Wellington Street West Bromwich West Midlands B71 1DR Lead Inspector Jayne Fisher Unannounced Inspection 26th January 2006 09:00 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 5 Wellington Street Address West Bromwich West Midlands B71 1DR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 532 3558 NONE Pioneer Care Limited Ms Sandra Horsley Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 5 Wellington Street is a semi-detached property which is rented from the Local Authority by Pioneer Care Limited and is located in West Bromwich. The centre of town is within a two-mile radius and there are local shops nearby. Public transport is good. The Home provides care for three service users with learning disabilities. All service users are fully mobile. The accommodation includes: a lounge/dining room, kitchen and toilet. There are four bedrooms one on the ground floor, three on the first floor, one which is used as an office/sleeping in room for staff. There is a domestic type bath and toilet. There is a quiet/activities room located on the first floor. There is a patio and large lawned garden to the rear of the property. This garden is well established and secluded. All of the service users attend local authority run day centres during the week, however staff are always on duty during the daytime in case a service user does not wish to attend day care or is unwell. The Home provides a range of activities for residents to undertake in their leisure time as well as an annual holiday. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between the hours of 9.00 a.m. and 12.00 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: case tracking, formal interviews with the home leader, and a member of support staff who were on duty. There was also a brief tour of the premises. Two of the three residents were at home during the varying stages of the inspection. They were happy to participate and one resident showed the inspector their bedroom. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of visits undertaken by the owner’s representative and an action plan submitted by the home following the last inspection. No. 5 Wellington Street provides intensive support for people who have a range complex needs. The majority of standards were examined at the last inspection and this report should therefore be read in conjunction with the previous inspection report to give a comprehensive overview. The findings of this inspection confirmed that staff are maintaining a high quality and person centred service. The inspector was made to feel very welcome and would like to thank service users and staff for their assistance and co-operation during the visit. What the service does well: There is a strong emphasis on supporting residents to take control of their own lives and to achieving individually appropriate life styles. Residents are given opportunities to maintain and develop social, emotional and independent living skills. There are good links with the local community and residents are able to choose community based activities. Staff are proactive in identifying any health care issues and ensuring residents receive appropriate guidance and treatment. Residents know that they can approach the home leader if they are unhappy or upset and there is a comprehensive complaints procedure in place. Through out the inspection residents looked happy, comfortable and relaxed in their surroundings. Residents are supported by a competent, caring and dedicated staff group, who clearly promote residents’ best interests and fully respect their rights. There is a strong commitment to staff training. The premises is furnished to a high standard. All communal areas are light and airy with modern furniture. Bedrooms are decorated and furnished 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 6 according to resident’s wishes. They contain lots of personal possessions such as televisions, hi-fi centres and videos. 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. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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): These standards were not assessed at this inspection. EVIDENCE: Progress was monitored towards an outstanding requirement in respect of service users’ terms and conditions of occupancy. These still require updating as previously required. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Care plans and risk assessments provide good guidelines for staff in delivery of care. Service users are enabled to make decisions through various support strategies. EVIDENCE: All care plans and corresponding risk assessments are currently being overhauled and updated in order to simplify, and make existing systems more efficient. A new assessment is also being introduced. This is a good initiative as some care plans were originally established a few years ago, and although they have been added to, as and when necessary, an overhaul of existing information would be beneficial. As this new system has not yet been implemented a full evaluation will be undertaken at the next visit. Examination of existing care plans confirms that good standards are being maintained. It was pleasing to see that new care plans and risk assessments had been established in order to reflect residents’ changing needs following issues identified by staff. For example, staff recently expressed concerns about a resident who has developed increased eating problems and as a consequence a comprehensive care plan and risk assessment was implemented. There is regular monitoring of care plans with monthly evaluations. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 10 Care plans cover all relevant subjects and aspects of care. Two out of the three service user plans had not been the subject of a six monthly review meeting with the resident and significant others which management acknowledge needs to be addressed. Interviews with staff and observations made during the inspection, confirmed that supporting residents to make decisions about their daily lives remains a priority. There is a person centred planning system in place with regard to care plans and this assists residents in exercising control how they receive care. Minutes from a recent residents’ meeting were available for inspection. It is clear that residents are encouraged to participate in this forum on an equal basis and seem comfortable in making requests regarding their preferred activities. All residents are self advocating but also have access to family members, day centre staff and other professionals. They also have access to peer support from other service users within the organisation. Care plans sampled contained comprehensive details regarding how residents are supported in managing their finances as previously requested. All care plans have a corresponding risk assessment which are also updated when residents’ need change. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 16 Service users are assisted to participate in a range of leisure and social activities in the home and within the community, which is supportive in helping them lead stimulating and meaningful lives. Daily routines are operated on the principles of choice and respect. EVIDENCE: All residents attend some form of external day care provision. As recommended at one resident’s recent review meeting, staff have been successful in encouraging attendance on a more frequent basis. During interviews residents spoke about their favourite activities within the home and talked about how they liked going out to the local pub. Weekly activity programmes are in place for two residents. There are evaluation sheets for activities undertaken which are completed by staff and are a useful monitoring tool. It was stated that a third resident’s activity programme is currently being reviewed in order to ensure that this is more reflective of their current preferences. Each resident has a diary which records daily events including activities and outings. On examination these demonstrated that residents enjoy a range of varied outings. For example, during a sixteen day period one 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 12 resident had been shopping, visited church, gone out to local pubs for meals in the evening and visited residents at another care establishment for a meal. Interviews with residents demonstrate that they are encouraged to participate in independent living skills tasks as observed during the visit. This was also confirmed during chats to residents, examination of daily diaries and care plans which identify daily living skills goals. One resident stated “I like doing the washing up” when asked about their favourite activity. Residents were seen clearing the table after having their breakfast and taking their dishes into the kitchen without prompting by staff. Since the last inspection residents have chosen to have a cat to add to their menagerie of pets which staff have fully supported. This emphasizes the family type atmosphere within the home. Daily routines are operated around residents’ individual choices and their rights are fully respected by staff. Residents confirmed that they can go to bed at a time of their own choosing. Daily diaries confirmed that bed times are variable and residents can have a lie in at weekends if they wish. As always, interaction between staff and residents was very positive with laughter and light hearted banter. Progress was monitored towards an outstanding requirement in respect of ensuring that there is more consistent checking and recording of cooked food temperatures. Improvements are still needed as these are not always being carried out by staff. It was also noted that nutritional screening and assessments had not been reviewed since implementation in 2004. These must be reviewed at least annually (or sooner if required). It was discussed with staff how to make these tools more meaningful. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 Staff provide sensitive and flexible personal support to service users and ensure that any health care needs are quickly identified and met. EVIDENCE: There are comprehensive care plans in place with excellent details of how residents prefer to receive support with personal care. Daily diaries record residents’ bedtimes and bath times. Residents choose their own clothing and hair style which reflect their individual personalities with support from staff as necessary. Health care needs of residents are well met. For example as already mentioned one resident had recently displayed eating problems which staff are proactively attempting to deal with. With the support from the community learning disability team and primary care team, staff are currently completing health action plans for all residents which is a good initiative. There are health care check lists in place to monitor routine appointments (although some now require updating for example with respect to chiropody). These confirm that residents receive regular dental and ophthalmic checks. Residents have also received annual health checks. Good efforts have been made by staff with regard to improving health care screening in respect of breast, testicular and cervical cancer. There are now comprehensive and informative care plans in place. Any refusals to undergo screening by residents are fully recorded and 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 14 discussed with the doctor with on-going review. Residents receive regular monthly weight checks. There are comprehensive care plans and risk assessments in place with regard to management of challenging behaviour. There is progress towards meeting outstanding requirements in respect of procedures relating to the control and administration of medication. It was pleasing to see that the pharmacist has recently visited and completed a written audit at the request of management. There is now a handover sheet in place with regard to key holding and the medication cupboard. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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): 22 There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon. EVIDENCE: The Home has a comprehensive complaints procedure with timescales which exceeds the national minimum standards, and details of the Commission for Social Care Inspection (CSCI). There is also a complaints procedure which has been produced in pictorial format. The Home has included the complaints procedure in the statement of purpose/service user guide as required. A service user who was interviewed stated that they would go to the home manager if they were upset or unhappy. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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): These standards were not assessed. EVIDENCE: These standards were assessed at the last inspection. There were only a small a small number of minor improvements identified. Discussion with management confirm that these are receiving action. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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): These standards were not assessed. EVIDENCE: Progress was monitored towards outstanding requirements. A full evaluation could not be undertaken as access could not be gained to staff personnel files as the home manager had forgotten to bring the key. Therefore training and supervision requirements will remain outstanding until the next inspection. There are currently some vacancies as a couple of staff have left since the last inspection. No new staff have been recruited although the manager is hopeful that this will take place in the future. Examination of the duty rota confirmed that staffing levels are being maintained with bank and permanent staff covering any shortfalls. The Registered Manager’s hours are now being included on the duty rota as previously requested. Management state that training is on going and progress is being made towards vocational training for staff, the majority of whom are undergoing an NVQ qualification. The central staff development and training programme requires updating as staff have received training which is not recorded on this document (for example fire safety training). Any other items relating to these standards and discussed during this inspection are contained within the Requirements section of this report. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 18 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): 42 Management ensure that so far as is reasonably practicable, the health, safety and welfare of residents is maintained and protected. EVIDENCE: An assessment of staff mandatory training was undertaken at the last visit. This demonstrated that training is on-going. There was one exception in respect of fire safety training. An Immediate Requirement was issued which received appropriate action. A sample of maintenance and service records were sampled. These confirmed that good health and safety practice is being adhered to. For example, there is weekly testing of smoke alarms and monthly fire evacuation drills with good records maintained of staff who participate in these drills. Fire safety equipment is checked annually and a risk assessment in respect of fire safety has recently been updated. Management stated that they are currently undertaking a review of health and safety practice. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 19 Some slight improvements are required with regard to food hygiene. For example, there needs to be more consistent checking of fridge and freezer temperatures. Frozen food had not been labelled with the date of freezing as previously requested. Outstanding items were monitored and outcomes are contained within the Requirements section of this report. Some improvements are still required. For example, the owner’s representative is not completing monthly reports (the last report available was July 2005). In addition visits are not being conducted on a monthly basis as required by the Care Homes Regulations 2001, Regulation 26. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 20 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 X 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 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X X X X X X 2 X 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(1)(b) Requirement Review the statement of condition of residency to include all information contained within Standard 5.2 of the National Minimum Standards for Younger People. (Previous timescale of 1/10/05 is not met) To ensure that this document is signed by either the service user and/or representative. (Previous timescale of 1/1/04 is partly met). To ensure that the service user plan is drawn up and reviewed (six monthly) with the involvement of family, friends or advocates. To carry out consistent checking and recording of cooked food temperatures and meals chosen by service users. (Previous timescale of 1/1/05 is not met). To review and update nutritional screening and assessment tools. To improve the control and administration of medication in the following areas: Timescale for action 01/04/06 2. YA6 15(1)(c) 01/05/06 3. YA17 17(2) 01/03/06 4. YA20 13(2) 01/05/06 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 22 1) To review and expand medication policy using guidelines issued by the British Pharmaceutical Society, June 2003. (Previous timescale of 1/1/04 is partly met). 2) To ensure staff sign the administration of medication procedure. (Previous timescale of 1/1/04 is not met). 3) To continue to progress plans to ensure all staff have received training in the safe handling of medication from an accredited trainer. (Previous timescale of 1/1/04 is partly met). 4) To ensure keys to the drug cabinet are held separate to any other master keys. (Previous timescale of 1/9/05 is not met). 5. YA21 12(1)(a) To obtain service users and/or family wishes regarding terminal care and formalities to be observed following death. To record preferences/wishes in individual service user plans. (Previous timescale of 1/4/04 is not met). To review and update the adult protection policy to include POVA procedures. (Previous timescale of 1/4/05 is not met). To ensure that all staff receive training in vulnerable adult awareness. (Previous timescale of 1/10/05 is not met). To make the following improvements to the environment: 1) To ensure all wardrobes are 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 23 01/05/06 7. YA23 13(6) 01/05/06 8. YA24 23(2)(b) 01/04/06 securely fixed to walls. (Previous timescale of 1/7/04 is not met). 2) To carry out a written risk assessment with regard to the use of electrical adaptors in documented liaison with the fire service. (Previous timescale of 1/10/05 is not met). 3) To ensure that there is more readable access to thermostatic controls on radiators which are currently inaccessible due to radiator covers. (Previous timescale of 1/10/05 is not met). To replace existing bedroom door locks with locks which have a thumb turn or other suitable over ride mechanism from the inside. (Previous timescale of 1/1/04 is partly met). To extend the choice of bathing facilities for service users to include the provision of a shower. (Previous timescale of 1/10/05 is not met). To provide restraint training for all staff in non-confrontational techniques. (Previous timescale of 1/1/04 is partly met). To provide training for all staff in challenging behaviour. (Previous timescale of 1/10/05 is not met). To ensure that 50 of the care staff team are qualified to NVQ 11 or above by 2005. (Previous timescale of 1/10/05 is not met). To ensure that all staff files contain up to date copies of terms and conditions of employment. (Not able to be DS0000004804.V280589.R01.S.doc 9. YA26 12(4)(a) 01/05/06 10. YA27 23(2)(j) 01/05/06 11. YA32 18(1)(c) 01/05/06 12. YA33 18(1)(a) 01/04/06 5 Wellington Street Version 5.1 Page 24 assessed at this visit). 13. YA35 18(1)(c) To ensure all staff receive 01/05/06 training in equal opportunities and disability equality. (Previous timescale of 1/10/05 is not met). To review and update the central staff training and development programme. The Home must introduce an 01/04/06 annual appraisal procedure for all staff. (Not able to be assessed at this visit). 14. YA36 18(2) 15. YA37 16. YA39 17. YA41 To improve the frequency of formal recorded staff supervision: to ensure that staff receive bi-monthly supervision sessions. (Not able to be assessed at this visit). 18(1)(c) To ensure that the Registered Manager is qualified to NVQ 1V in care and management by 2005. (Not able to be assessed at this visit). 24 To review and further develop quality assurance system to incorporate feedback from stakeholders and families. (Previous timescale of 1/5/05 is partly met). 19(1)(b)37 To obtain and hold information and documents in respect of persons carrying on, managing or working at a care home as listed in Schedule 2 and 4 of the Care Home Regulations 2001. (Not able to be assessed at this visit). 13(4)(a) 01/04/06 01/05/06 01/04/06 18. YA42 To carry out a written risk 01/04/06 assessment to identify and undertake control measures with regard to unsecured substances hazardous to health which are held in the kitchen. (Previous timescale of 1/1/05 is not met). DS0000004804.V280589.R01.S.doc Version 5.1 Page 25 5 Wellington Street 19. YA42 13(4)(c) To ensure that all food frozen by the home is labelled with the date of freezing and use by date. (Previous timescale of 1/9/05 is not met). 01/04/06 20. YA43 26 To ensure more consistent checking and recording of fridge and freezer temperatures. To ensure that copies of the 01/04/06 monthly reports from visits undertaken by the Owners representative are available on the premises and a copy forwarded to the Commission for Social Care Inspection. To ensure that the reports contains information in sufficient detail as required by the Care Homes Regulations. (Previous timescale of 1/9/05 is not met). To ensure that visits are undertaken on a monthly basis by the Owner’s representative in order to form an opinion as to the conduct of the home. 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 YA23 Good Practice Recommendations To ensure that two staff signatures are obtained for all financial transactions made on behalf of service users which should be recorded in a bound book. 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 Page 26 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 5 Wellington Street DS0000004804.V280589.R01.S.doc Version 5.1 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. 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