Inspection on 26/08/05 for 58 Worlds End Road

This inspection was carried out on 26th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

58 Worlds End Road 07/02/08

58 Worlds End Road 24/01/07

58 Worlds End Road 17/02/06

58 Worlds End Road 17/12/04

58 Worlds End Road 29/07/04

58 Worlds End Road 18/02/04

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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 09/07/2008.

CARE HOME ADULTS 18-65 Worlds End Road, 58 58 Worlds End Road Handsworth Wood Birmingham B20 2NS Lead Inspector Gerard Hammond Unannounced 26 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Worlds End Road, 58 Address 58 Worlds End Road Handsworth Wood Birmingham B20 2NS 0121 523 5493 0121 523 5493 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Milbury Care Services Limited Ms Elizabeth Brown Care Home 4 Category(ies) of Younger people with learning difficulties registration, with number of places Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. 2. To accommodate one named person with a physical disability, subject to regular review of her care needs. Date of last inspection 17 December 2004 Brief Description of the Service: 58 Worlds End Road provides accommodation, care and support for three adults with learning disabilities. The house is a domestic scale, semi-detached property situated in a well-established residential neighbourhood in the Handsworth Wood area of Birmingham. There is a range of community facilities within the immediate locality, including shops, places of worship, GP surgery and parks. Main public transport routes are within walking distance. On the ground floor of the house, there is a lounge to the front, and a kitchen and separate dining room at the back. There is also a laundry room, an assisted bathroom with w.c., and one residents single bedroom on this floor. Upstairs are two further bedrooms, another bathroom with w.c. and a small room used as an office. To the rear of the property is an enclosed garden with ramped access and handrails and small paved area. The drive at the front of the house can accommodate one vehicle, but there is parking on the road outside. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Direct observation and sampling of records (including personal files and care plans and other documents) were used for the purposes of compiling this report. The Inspector met all three residents but was unable to interview them because of their communication support needs and learning disabilities. The Home Manager was formally interviewed, and a tour of the premises completed. What the service does well: What has improved since the last inspection? What they could do better: Care planning needs to be developed. In particular, records need to be “tidied up” and organised better, so that important information about how people should be supported is easy to find. Plans should include people’s goals, showing what the desired outcomes are and how these can be measured. These should be looked at when the plan is Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 6 reviewed, and a judgement made about what has worked and what might need to be changed. Risk assessments also need developing, and it may be that some staff need training or guidance to ensure that they know how to make effective use of them. Opportunities for residents to be involved in activities that are valued and purposeful need to be improved, in quality, range and frequency. It may be that staff require some extra help to achieve this. The way in which people’s activities are recorded needs to be improved. This should include more detail and show why particular activities are undertaken. Doing this will provide valuable information for future planning and judging whether things are improving or not. 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. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Residents’ needs have been assessed, and these should now be reviewed. EVIDENCE: There have been no admissions since the last inspection, but an appropriate procedure is in place to assess the needs of any prospective future resident. Sample checking of one resident’s personal file revealed a completed E.L.S.I. assessment (Everyday Living Skills Inventory), which provides detailed information about individual abilities and support needs. However, this document was not dated, and it was not possible to ascertain when it had been completed, or if it had been reviewed. It is recommended that people’s assessments be reviewed, so as to provide an accurate statement of support needs. This is an essential exercise in order to obtain a current baseline from which to work, so that care plans can be properly reviewed (see Standard 6 also). Attention is drawn to the desired outcome for this Standard, which indicates that assessments should be a statement of people’s aspirations, as well as their needs. It is therefore further recommended that person-centred approaches be promoted in carrying out this work, in keeping with the aspirations of the Government White Paper “Valuing People”. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 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 standard(s) 6, 7 & 9 Care plans need developing, to include residents’ goals as well as their assessed support needs, and these need to be reviewed and evaluated appropriately. Residents are supported to make choices and decisions, but this is limited by their learning disabilities and communication support needs. Responsible risk taking is recognised as an essential component of promoting individual independence. However, risk assessing needs to be developed in order to support care planning more effectively. EVIDENCE: Care plans are in need of significant development. As indicated in the previous section (Standard 2), this process should commence with a review of individuals’ statements of needs and aspirations. It is also recommended that some thought be given to information management prior to this. Files are in need of a general “tidy up”: material that is old or has been superseded should be removed and disposed of, or archived, as appropriate. It is important that anyone seeking information from the file should be able to locate it quickly and easily, and not be put at risk of following guidance that is out of date. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 10 A positive attempt has been made to present information about residents’ needs in a user-friendly format entitled “Communication Passport”. These include photographs and some general information about likes and dislikes. However, significant by its absence is any detailed information about how each person actually communicates. All of the people living in this house require detailed communication guidelines for staff to follow. One resident’s records refer to “objects of reference” being used to support communication. However, there is no indication of which objects are currently in use, or of what meaning is attached to them or how they are actually used. This whole area requires a good deal of work, so that knowledge that the care team undoubtedly has about the ways in which residents express themselves, is accurately recorded, and incorporated into individual care plans. The importance of this should not be underestimated – communication, after all, underpins all other interactions. Care plans should also include goals with outcomes that can be measured. Some of these may well be guided by individuals’ known aspirations. Others will be identified as a result of people’s known needs or their risk assessments. Goals should be evaluated at review, and changed, amended or continued as appropriate. Whole care plan reviews should take place at least every six months, and written records kept. These should indicate who takes part, and how decisions are made. In this house, choices and decision-making are restricted to fairly mundane matters, (such as what to eat or whether to go out) because of people’s learning disabilities and limited communication. Staff have to use their knowledge of individuals’ mannerisms, body language and gestures to interpret their wishes. It is important that every chance is taken to develop people’s capacity to communicate more effectively (both staff and residents) so as to enhance opportunities for making better choices. Risk assessments were also sampled, and seen to be in need of development. It is not clear that people writing risk assessments fully understand their purpose and know how to incorporate them into care planning appropriately. Hazards are not always correctly identified. Control measures should inform the guidance that is then included in people’s plans of care. Risk assessments should be directly cross-referenced to the element(s) of the care plan(s) to which they relate, and vice versa, so that tracking from one to another is simple. A good index for both care plans and risk assessments may be helpful in this regard. It was noted that risk assessments were indexed, but care plans were not. Consideration should be given to whether or not staff need training or extra support to use risk assessments more effectively. In conversation with the Inspector, the Manager demonstrated an open attitude, and a willingness to consider alternative ways of working, so as to develop practice, and the service overall, for the benefit of the residents. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 15, 16 & 17 Residents are able to take part in appropriate activities and to access the local community, but opportunities lack variety and purpose. These should be further developed in conjunction with their care plans. People are supported to maintain contact with families and loved ones. Residents’ rights are respected, and they are supported and encouraged to do things for themselves, so as to promote their personal independence. Residents have access to a balanced, nutritious diet. EVIDENCE: All of the residents in this house have been able to access placements in local colleges during term time. Recent changes to the availability of provision have meant that alternative opportunities are now being sought. The last inspection report suggested that consideration should be given to ways in which the range of available opportunities could be extended, and this continues to be the case. Sample checking of records revealed that activities are limited. Entries merely state things like “tidy room”, “clear up table”, “tidy drawers”, “go out for drive”, ”relax”, “nails”, “puzzle”, “short walk”, and so on. It was also noted that the daily diary recordings did not correspond with what was written in individual activity plans. No indication was given whether or not an Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 12 activity was offered but declined. There was a good tool on the file for assessing choices and options, but this was not being used effectively. The support needs of the three people currently living in the house are complex and varied. One resident has an Autistic Spectrum Disorder. She is said to have a short attention span, and to be difficult to engage. It was reported that motivating people to go out or to participate in activities has also proved problematic in the past. It was noted that on the day of the inspection that residents spent most of the day in the lounge and did not appear to be effectively engaged in purposeful activity. It must be acknowledged that supporting individuals with such complex and varied care needs is no simple task. It should also be recognised that residents had returned from a short holiday away late on the previous evening, and were said to be tired from the travelling. However, activities need to be planned in relation to individuals’ assessed needs. Opportunities need to be actively sought, so that activities are purposeful. This exercise needs to be linked directly to the development of people’s care plans, and specifically to their individual goals and aspirations. Activities chosen with residents should seek to address their identified needs – they might be therapeutic, for learning or maintaining a particular skill, just for fun, or any combination of these things. Consideration should also be given to how chosen activities can promote individuals’ active participation in the life of the community in which they live. It may be that additional professional assistance should be sought, for example from an occupational therapist, so as to increase the capacity of the staff team to develop appropriate activity programmes with residents. Activity recording in general needs to improve. This should include statements about the purpose of the activity and more detail about what actually happened. This information will be particularly helpful in guiding future planning. Wherever possible, people living in the house are encouraged and supported to maintain contact with their families and friends. Particular efforts have been made in one instance to trace and establish contact with the family members of one of the residents, and these have met with considerable success, much to the delight of everyone involved. This is a really good example of members of the care team being proactive and taking the initiative, and this should be commended. Routines and “house rules” were observed to be flexible. On the day of the inspection, residents enjoyed a lie-in after travelling back home from holiday the previous evening. Records and direct observations confirmed that efforts are made to encourage people to do what they can for themselves, and to be involved in things around the house, so as to promote their personal independence. Records of meals taken indicated that residents enjoy a nutritious and varied diet. Food stocks were seen to be ample, with fresh produce available. Material is being gathered to provide pictorial aides in order to support people making choices about what they would like to eat. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 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 standard(s) 18, 19 & 20 Personal support is delivered in an appropriate manner, but care plans need development to include more detail about individual preferences. Some aspects of individuals’ healthcare promotion are in need of improvement. General practice in the handling and administration of medication affords protection to the people living in this house. EVIDENCE: All of the people living at 58 Worlds End Road require support in their personal care. As reported earlier, care plans are in need of development so that clear guidance is given as to how support should be given. It is important that guidance is detailed and specific, as residents’ communication support needs mean that it is not easy for them to indicate their preferences. Staff were observed interacting with residents, and this was done in a warm and friendly manner that was also appropriately respectful. Records indicated that referrals have been made to a range of healthcare professionals and members of the multi-disciplinary team (including GP, dietician, speech and language therapist, occupational therapist, community nurse, etc.) as required in accordance with individual need. However, one person’s file contained a chart for weight monitoring, but no guidance was given as to how frequently this should be done, and there were gaps in the Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 14 recording. A chart for monitoring epileptic seizures was also seen: it was not possible to see what year this related to, and the single entry did not identify the type of seizure, as indicated. The care plan relating to this also requires development so as to include clear guidance about the circumstances in which the emergency services should be called out. This resident also has a diagnosis of a serious illness, but no care plan has yet been developed to address issues of monitoring and support for the future. This must be addressed, and is a requirement of this inspection report. The accident book was seen, and complies with current data protection legislation. It was noted that reports are being filed with individual personal records, as appropriate, but that currently there is no way of tracking where reports are from the accident book itself. It is recommended that the counterfoil stub in the book be marked with the date of the report and the initials of the person to whom it relates. Sample checking of personal records revealed an occasion when one resident had a fall and had to be lifted from the floor using a hoist. No trace of an accident report or of the report to CSCI required under Regulation 37 (Care Homes Regulations 2001) could be found It is further recommended that the accident book be marked to remind staff of the need to report such matters appropriately, and that this is supported by a “read and sign” sheet, to ensure that all members of the care team are aware of their responsibilities in this regard. Medication administration records were sample checked, and there were no gaps in recording. Medication stocks were also sampled, and found to be in order. All medicines were appropriately and securely stored. Requirements made at the time of the last inspection have been complied with, and general practice improved. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 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 standard(s) 22 & 23 Residents’ learning disabilities make it difficult to assess fully whether or not they consider that their views are listened to and acted upon. General practice within the Home offers protection from abuse, neglect and self-harm to the residents. EVIDENCE: An appropriate complaints procedure is in place, but this has little relevance for the residents of this house, due to their learning disabilities. At the time of the last inspection it was reported that two complaints had been investigated by the organisation previously, and that procedures had been followed appropriately. No complaints have been received since then. All staff, with the exception of one new member, are said to have received training in the Protection of Vulnerable Adults From Abuse, though the chart on the office wall did not show this (See Standard 35 also). An appropriate policy is in place. Sample checking of the personal file of the most recently appointed member of staff revealed that CRB and POVA checks had been completed satisfactorily. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 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 standard(s) 24 & 30 The people living at 58 Worlds End Rd. enjoy a house that is comfortable, safe and homely. The house is kept clean and tidy, and a good standard of hygiene maintained. EVIDENCE: 58 Worlds End Road is a domestic scale house, and has the environmental “feel” of an ordinary family home. It is clear that maintenance and refurbishment has been carried out on a regular basis, and that work is ongoing. The manager advised that new floor coverings for the lounge and the dining room are on order, and due for fitting in the near future. Residents’ bedrooms are individual in style, with personal possessions and effects in evidence. One person has items of snoezelen-style equipment in her room to promote her relaxation and provide sensory stimulation. The kitchen is now in need of refurbishment, as the units are very worn and well past their best. The extractor fan in the downstairs bathroom is in need of cleaning to remove collected dust, and ensure its efficient functioning. A light-shade is also required in this room, and the toilet seats in both bathrooms require securing properly. A good standard of hygiene is maintained in the Home, and the house is kept generally clean and tidy. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 & 36 General recruitment practice offers appropriate support and protection for residents, but some personnel records are incomplete. A staff training and development assessment is required in order to make an accurate judgement about whether or not individuals are appropriately trained. Staff supervision is not yet totally up to the required standard, but has improved significantly. EVIDENCE: As reported previously, the records for the most recently appointed staff member were examined. CRB and POVA checks were in place and most other documentation required was also present. However, there was no copy of her birth certificate, or a recent photograph. Three other staff files sampled did not contain photographs either. The chart in the office mapping training was not fully up to date, and a requirement of this inspection is that the Manager complete a current training and development assessment for each member of staff, and forward this to CSCI. This should include details of all training completed by each person, and highlight any gaps, including where refreshers are required. Where training is shown as being outstanding or required, the assessment should show when this is scheduled and who is to deliver it. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 18 Sample checking of staff supervision records revealed a variable success rate in terms of meeting the requirements of this standard. However, it is clear that the Manager has made solid efforts to address this, and is continuing to do so, that the current situation represents a marked improvement since the last inspection, and that this should be acknowledged. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 General practice promotes the health safety and welfare of people living in the house. EVIDENCE: Safety records were examined and showed that the fire alarm and emergency lighting systems have been serviced and checked regularly as required. Fire drills have been carried out twice in the last six months. The assisted bath and lifting equipment has been serviced. Portable appliance testing has been carried out on electrical equipment, and the hard wiring certificate is in date, as is the Landlord’s Gas Safety Certificate. Packages of food stored in the fridge were correctly labelled with the date of opening. The record of testing of water temperatures was also seen, and completed as required. Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 2 2 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Worlds End Road, 58 Score 2 2 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 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 6 Regulation 15 (1-2) Requirement Care plans should be developed to include individuals personal goals, and as indicated in the main body of this report. Whole plan reviews should take place at least every six months, with written records kept showing who takes part and how decisions are made. Risk assessments need developing so that hazards are identified correctly, and control measures are incorporated into individual care plans appropriately. Risk assessments should be cross-referenced to the care plan(s) to which they relate, and vice versa. All residents activity opportunities must be reviewed and action taken to improve their quality, range and frequency. Activity recording should indicate what the purpose of each activity is, and include sufficient detail to support judgements about how successful it has been in achieving its purpose, to inform Timescale for action 30 November 2005 2. 9 13 (4) 30 November 2005 3. 12 & 13 16 (2m-n) 30 November 2005 Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 22 future planning. The action plan should indicate how this will be taken forward. 4. 19 12 (1) 13 (1) 15 (1-2) One resident has been diagnosed 31 October with a serious illness. Her care 2005 plan needs to be developed to include detail of how she is being supported in this regard currently, and how it is proposed to continue meeting her health care needs for the future. Ensure that all acidents in the Home are correctly recorded, and reports required under Regulation 37 (Care Homes Regulations 2001) are made to CSCI. The kitchen should be refurbished. Forward an action plan to CSCI indicating work schedule and proposed timetable. Clean the extractor fan in the downstairs bathroom, and fit light shade to exposed bulb. Repair loose toilet seat fittings in both bathrooms. Ensure that all required documentation is retained on the personal files of all people working in the Home. Forward to CSCI a current staff training and development plan as indicated in the main body of this report Ensure that all staff receive formal supervision on a minimum number of six occasions in any twelve month period. Within one day of receipt of this report 5. 19 37 6. 24 23 (2) 31 October 2005 7. 24 23 (2) Within one week Within one day 31 October 2005 8. 9. 24 34 13 (4c) 17 (2) 19 (4) Sch.2 Sch.4(6) 18 (1c) 10. 35 31 October 2005 11. 36 18 (2) 30 November 2005 Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 23 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 2 Good Practice Recommendations Review residents assessments so as to inform care plan development appropriately, and adopt person-centred approaches as indicated by Valuing People. Tidy existing personal files so as to ensure that all information retained is current and accurate. Make positive use of indices and cross-referencing to link care plans and risk assessments and support better information management. Mark the counterfoil stubs in the accident book to identify the location of completed reports. 2. 6 3. 19 Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Worlds End Road, 58 E54 S16931 Worlds End Road 58 v246941 260805 Stage 4.doc Version 1.40 Page 25 - 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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