Inspection on 10/10/07 for 68 Bescot Road

This inspection was carried out on 10th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

68 Bescot Road 29/04/09

68 Bescot Road 30/04/08

68 Bescot Road 02/10/06

68 Bescot Road 28/11/05

68 Bescot Road 05/08/05

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 68 Bescot Road 68 Bescot Road Walsall West Midlands WS2 9AE Lead Inspector Sue Woods Unannounced Inspection 10th October 2007 09:50 68 Bescot Road DS0000062047.V337911.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 68 Bescot Road DS0000062047.V337911.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. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 68 Bescot Road Address 68 Bescot Road Walsall West Midlands WS2 9AE 01922 648758 0121 525 8492 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited Jane Anderson Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd October 2006 Brief Description of the Service: 68 Bescot Road is a care home that is owned and managed by Caretech following the ‘takeover’ of Lonsdale Midlands Ltd in 2006. The home offers nursing care and personal support to up to eight individuals with a learning disability with health and/or complex social care needs, plus degrees of behavioural challenge. The home is divided into two areas. A respite ‘unit’ is situated on the ground floor and a long-term ‘unit’ on the first floor. A passenger lift is available. The two units have the same layout and comprise of four single occupancy rooms, (some with en suite shower facilities) a shared bathroom and two separate toilets, lounge, dining room, and kitchen. The two units operate independently of each other although staff work between both. The external area of the home comprises of a car park at the front and small rear garden. Entrances and exits are ramped to ensure access by people with mobility difficulties. The home aims to provide its residents with a secure, relaxed and homely environment in which their care, well being and comfort are of prime importance. This is stated to be achieved through a programme of activities designed to encourage mental alertness, self-esteem, and social interaction with other residents and with recognition of core values that are fundamental to the philosophy of the home. The core values being Privacy, Dignity, Rights, Independence, choice, and fulfilment. Information about fees was unavailable at the time of this inspection People who use the service and their representatives are able to gain information about this home from the Statement of Purpose, Service User Guide (currently being updated) and inspection reports produced by Commission for Social Care Inspection. Inspection reports can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of 68 Bescot Road was carried out on 10th October 2007 from 09.50 am until 04.00 pm. The inspector phoned the home on 8th October to say that she was coming. This was because one person who lives at the home may be upset by an unexpected visitor. The inspection reviewed all 22 key standards and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. The inspector met with three people who live at the home and spoke in private with three staff on duty. The inspector also spent time with the home’s acting manager and the organisation’s area manager to look at a sample of care plans and other documents that are referred to within this report. Surveys were sent out prior to the inspection to people living at the home. One was returned and the inspector spoke with a relative on the morning of the inspection. Prior to the inspection visit the registered manager completed and returned an Annual Quality Assurance Assessment (AQAA). Information contained within this document did not accurately reflect findings on the day of the inspection. The area manager was made aware of this. What the service does well: A health care professional recently commented that she was ‘Impressed by the homely feel’ to Bescot Road. The acting manger felt that communication is good between the home and health and social care professionals. Staff feel that they work well together and individual examples of practice seen on the day of the inspection demonstrated that staff are able to effectively communicate with people living at the home. People living at Bescot Road said they liked the home and via a survey someone commented that staff ‘always’ treat them well. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 68 Bescot Road DS0000062047.V337911.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 68 Bescot Road DS0000062047.V337911.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): Standard 2 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. An improved assessment and admissions process will mean that people who move in to Bescot Road or stay there for respite can expect to have their care and support needs identified. People are unable to see for themselves if the home is suitable as the Statement of Purpose or Service User Guide haves not yet been updated. EVIDENCE: Since the time of the last inspection of the home there is evidence that the organisation has reviewed its admissions procedures and there is now a clear process to follow. Assessments will identify at an early stage if the home can meet the person’s needs and then inform the care plan. The file of the last person to be accepted for respite at the home was seen and there was evidence that assessments by health and social care professionals had been carried out prior to admission. The Statement of Purpose and Service User Guide were unavailable for review as the acting manager is in the process of updating them. The acting manager 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 9 is currently trying to establish the level of fees and will then share this information with the people who live or stay for respite at the home. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6,7 and 9 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Care plans for people living at Bescot Road do not accurately reflect individual needs meaning that people may not be receiving the support they require. Likewise the home cannot demonstrate that risks are assessed to keep people safe or that people are involved in making decisions. EVIDENCE: The inspector saw two care files and an example of the ‘new look’ files that are currently being developed by the acting manager and the area manager. It was very difficult to find information in the existing files and, as found during previous inspections, the quality varied. Given the managers acceptance that the files are in urgent need of review the inspector only reviewed key information to support behaviours identified at the time of the inspection. In brief discussions with some of the people living at Bescot Road it was found that they are involved in making some decisions about how they spend their 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 11 leisure time for example, however, the inspector could not establish by looking at the care plans that people are supported to make decisions in other areas of their lives. Risk assessments seen were very basic and there was no evidence to show that they had, on all occasions, been reviewed. Again the acting manager and the area manager are looking to review all risk assessments. A padlock seen on a wardrobe door could not be supported by a risk assessment and thus was restricting the person from accessing their belongings. The arrangement was not recorded in the care and support plan. (See requirement standard 18). Requirements made at the time of the last inspection of the home remain unmet and this will affect the outcome rating for this section. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12, 13, 15 16 and 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People enjoy regular contact with family and leisure opportunities of their choice when available. The acting manager wants to improve opportunities for everyone. The lack of a working menu means that the home cannot demonstrate that people eat a healthy diet reflecting their individual dietary needs. EVIDENCE: The home still cannot show that people living at Bescot Road are getting access to a reasonable range of activities both within the house and within the community although some people gave examples of places they have visited and places they plan to visit at the time of the inspection. For example one man is looking forward to a visit to the cinema and one man enjoys local walks. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 13 The acting manager and the area manager both said that they want to improve opportunities for people and are looking at college courses for the future. Family links are promoted and encouraged and family members support the home with fund raising events. One relative who spoke with the inspector said that things were currently improving at the home. A survey said that people are not able to do what they want at weekends although they can during the week. The home has a ‘rolling menu’ that is not currently being followed. A menu board is in place to tell people what is on offer each day although it is not being used successfully at the moment. Staff have access to information in relation to people’s special dietary needs and have worked with health care professionals to develop this information. One man is aware of his cultural needs although chooses to eat food that he enjoys. Staff support his decisions although it is not recorded in the care plan. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18, 19 and 20 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People living at Bescot Road and are being placed at risk as policies do not support practices within the home in relation to the administration of medication. People living at the home are not receiving consistent support in relation to managing identified behaviours leading to incidents that could possibly be avoided. EVIDENCE: Care plans are in the process of being reviewed and updated to make sure that likes and dislikes of people are recorded and taken into consideration when planning care and support. Currently support plans are either available but not being followed or are unavailable. Likewise the home could not evidence that all routine health care appointments are taking place. The support plan for one person living at the home was not followed on a number of occasions during the inspection leading to confusion, and distress to 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 15 the individual. The manager intervened to make the situation safe and recognised that consistency and constant monitoring is needed. He did however suggest that the 3 to 1 staff ratio was not needed. (See requirement standard 6). The area manager committed to instigate an immediate review of the situation relating to one person living at the home. A padlock seen on a wardrobe door had been fitted in an attempt to keep someone safe following an incident. However the practice could not be supported by a risk assessment and the care plan suggested a different course of action. Medication arrangements were discussed at the time of the inspection with the deputy manager. It was identified that the administration of medication is not straightforward especially due to the location of the cabinets. Registered nurses are currently required to write on the medication administration sheets (MAR sheets) using information from the boxes supplied by relatives. When reviewing this practice it was identified that the homes medication policy did not refer to medication procedures for people receiving respite care. This was later confirmed by the manager and the area manager who couldn’t find the medication policy at all. Given previous requirements in relation to the administration of medication this is of concern. Gaps were again found on MAR sheets relating to errors of recording and not errors in administration. The area manager ordered an immediate review of medication procedures at the home. No controlled drugs are kept at the home or brought into the home. Protocols relating to PRN (medication given as and when required) were vague requiring explanation. The area manager confirmed they needed ‘quantifying’. Some routine health care appointments are recorded in care plans but not all. Events notified to CSCI demonstrate that medical support is sought during health care emergencies. The acting manger also felt communication is good between the home and health and social care professionals. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People have information to help them to make a complaint however some restrictive practices have been accepted and not challenged suggesting people are unaware of their rights. EVIDENCE: The complaints procedure, in an easy read format, was seen on files and on the wall in the lobby. The acting manger has received two complaints that were properly logged and responded to. He has also started recording compliments about the home. For example a social care professional was ‘Impressed by the homely feel’. When talking with staff they were aware of complaints and whistle blowing procedures. Staff would feel confident to identify poor practice if they saw it however staff have not all received training in ‘Adult Protection’ (See requirement for standard 32). As noted earlier in the report some practices within the home are seen to be restrictive and often with no explanations to justify them. This was also noted at the time of the last inspection of the home when a requirement was made. (See requirement for standard 18) At the time of the inspection the area manager audited the cash tin of one person living at the home and found money as per the records. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well decorated and generally well maintained providing the people who live there with a comfortable place to live. EVIDENCE: During a tour of the home it was noted that all areas were clean and tidy. Redecoration had recently taken place in a number of areas. Some bedrooms were seen to be quite ‘bare’ however the acting manager stated that this is through choice. Furniture was broken in one respite bedroom that was currently unoccupied and the door would not close properly. Some fire doors were propped open but area manager said this was due to the paint drying. Wedges were removed immediately. Minor repairs pointed out by the inspector had already been referred to the maintenance team by the acting manager. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 18 The acting manager advised that data sheets and risk assessments to support the use of cleaning products were available in the office although they were not seen. He stated that they had been done the day before the inspection by a visiting manager within the organisation. It is recommended that facilities be provided for staff to secure their belongings while on shift. It is also recommended that consideration be given to having a larger office. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 and 35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People living or staying at Bescot Road are supported by a committed staff team although people may be at risk if the home cannot demonstrate that staff working at the home have been checked for suitability prior to their employment. Long hours, unpaid breaks and lack of appropriate facilities and risk assessments may effect the health and wellbeing of the staff team, which will then impact on the quality of the service received by the people living at the home. EVIDENCE: Staff continue to work 12 hour shifts and the recommendation made by CSCI to shorten them has not been actioned. CSCI continues to recommend this is reviewed especially given that the hour and a half unpaid break is often not taken as staff prefer to finish on time. Staff also have to leave the premises for breaks as there are no staff facilities on site. When staff action their right to take a break staffing levels within the home are immediately affected. The area manager is reviewing this arrangement. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 20 Staff who spoke with the inspector were aware of their roles and responsibilities. One bank staff member on duty was seen to communicate effectively with a man who used signs to communicate. Staff felt well supported and one new staff member thought his induction had been good. The inspector asked to look at three files as part of this inspection. Only two were available. The file of the bank worker, working at the time of the inspection was unavailable and the acting manager had no emergency contact details for her at all. One file did not contain all required information however the area manager contacted the organisations head office and was able to get the required information faxed over to demonstrate a robust recruitment process. The homes AQAA suggests six support staff and one nurse on each shift. Numbers on the day of the inspection were six including the nurse however it was acknowledged that some people were attending day services. Staff training records were poor and did not demonstrate that staff have received even mandatory training on all occasions. The rota showed that some courses were planned and the area manager has already requested information of training gaps to address this issue. (See requirement standard 42) One pregnant worker had not had a risk assessment to support her working at the home although staff were aware of safeguards to protect her. (See requirement standard 42). 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 37, 39 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Bescot Road is not currently a well run home. A number of requirements made by CSCI during previous inspections to make things better have not been met. People are however kept safe by good health and safety monitoring practices and recent management changes have effected positive changes that will ultimately improve the quality of the lives of people living at the home. EVIDENCE: The acting manager had been working at the home for four weeks prior to the inspection. The area manager had been overseeing the home since 1st September 2007. There is evidence to suggest that within this time frame issues have been identified and they are in the process of making improvements in a number of areas. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 22 However it must be noted that requirements made by CSCI following the last two inspections dating back to 2006 have still not been met. The homes AQAA completed by the registered manager, currently on leave, suggests that requirement have been addressed. This is not the case. The acting manager and the area manager fully acknowledge all the issues raised within this report and are prioritising a plan of action to address them. There is recognition that the views of people who live at Bescot Road are not being actively sought and they plan to use the organisations quality assurance systems to address this. Not all policies and procedures were in place although the area manager acknowledged that they were available within the organisation. Health and safety issues have been raised throughout this report however it was positive to see that routine safety checks were up to date and input had been sought from other managers to achieve this. It was also positive to note that the area manager had identified shortfalls in the service prior to the inspection and had taken action to bring in a manager in an attempt to raise standards. NOTE: Following the inspection the area manager wrote to CSCI outlining an interim action plan to address issues raised at the time of the inspection. The plan included the review of identified care and support plans and risk assessments to support identified behaviours. She has also brought in the support of a second manager within the organisation to assist with meeting these objectives. This action has been considered when reviewing the quality outcome for this section. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 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 2 33 2 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 1 X 2 X 2 X X 3 X 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement The home must develop and implement care and support plans that demonstrate how all aspects of personal care and support are to be delivered. This is to ensure that staff know how people like to be supported and any specific needs are identified and thus can be met. It is also to ensure the safety of the individual (and staff supporting them) at all times. Previous timescales for compliance 30/06/06 and 30/11/06 not met People must be supported to make decisions that affect their lives. Records must then detail all decisions made to demonstrate that these processes are in place and that people are actively involved in them. Previous timescales for compliance 30/11/06 not met 3 YA18 12 The home must ensure that any restrictions placed upon a person DS0000062047.V337911.R01.S.doc Timescale for action 29/11/07 2 YA7 12 (2) (3) 29/11/07 29/11/07 68 Bescot Road Version 5.2 Page 25 are made only after full assessment of risk and a support plan demonstrates that it is the appropriate cause of action. This is because people have the right to access their belongings unless it is not safe for them to do so. Previous timescales for compliance 30/11/06 not met 4. YA9 13 (4) (C&D) Any risks to a person living at the home or to others living or working with that person must be assessed and then as far as possible the risk must be eliminated or reduced. This is to make sure that unsafe practices are stopped or reduced to an acceptable level. Written records must support that this process has taken place and that risks are regularly reviewed. Previous timescales for compliance 31/03/06 and 30/11/06 not met 5. YA12 16 (2) (m&n) The home must evidence that people are enabled and supported to pursue interests/hobbies which are geared to the individuals choice and use the local facilities to undertake a variety of activities in addition to their main and regular routines Previous timescales for compliance 31/03/06 and 30/11/06 not met 6. YA19 13 (1)(b) The management must evidence that service users healthcare needs are being met, and procedures for routine screening DS0000062047.V337911.R01.S.doc 29/11/07 29/11/07 29/11/07 68 Bescot Road Version 5.2 Page 26 and the monitoring of service users’ health with regard to potential complications, are adequate. All service users must be enabled to receive annual health checks, such as attending `well person clinics and records maintained Previous timescales for compliance 30/11/06 not met 7 YA20 13 (2) 8 YA33 18 (1) (a) 9 YA34 19 (1) The home must develop and 09/11/07 implement a policy to support the administration, recording and storage of medication that is relevant to the home. This is because staff do not have guidelines to follow in relation to safe working practices particularly for people receiving respite within the home. Staffing levels must be reviewed 09/11/07 to ensure that here are sufficient staff on duty at all times to meet the assessed needs of the people living at the home. The home must ensure that 09/11/07 information obtained to establish the fitness of workers to work with vulnerable adults is stored and retained in line with the most recent guidance set by the Commission for Social Care Inspection. This is to demonstrate that people working at the home do not pose a risk to vulnerable people. Previous timescales for compliance 30/11/06 not met 10 YA42 18 (1) (a) The home must ensure that an assessment of risk is undertaken to ensure that pregnant workers are protected while at work and DS0000062047.V337911.R01.S.doc 09/11/07 68 Bescot Road Version 5.2 Page 27 that they are fit to be working. 11. YA42 18 (1) (a) The home must ensure that staff health and safety competence training and all other mandatory training is kept in date to ensure that staff have the knowledge and skills to safely support people living at the home. Records must be available to reflect this has happened. Previous timescales for compliance 30/11/06 not met 12 YA37 9 (2) Effective management arrangements must be in place, to ensure the continuing development and improvement of the home. (Timescale to coincide with acting managers last day working at the home) The views of people living and staying at Bescot Road must underpin all self-monitoring and development by the home. This is to ensure that people feel involved and consulted in all aspects of their lives and that their views and opinions are valued. 19/11/07 29/11/07 13 YA39 24 (3) 29/11/07 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 2. Refer to Standard YA24 YA32 Good Practice Recommendations The home should ensure that staff have facilities to store belongings while working at the home. The home should continue to work toward meeting Sector Skills Workforce targets of 50 of care staff having achieved an NVQ level 2 or above. DS0000062047.V337911.R01.S.doc Version 5.2 Page 28 68 Bescot Road 3. 4 YA33 YA24 Care staff shifts should be reduced from twelve hours. Consideration should be given to having a larger office on the premises or have facilities for people to meet in private. 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 29 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 68 Bescot Road DS0000062047.V337911.R01.S.doc Version 5.2 Page 30 - 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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