Inspection on 02/10/06 for 68 Bescot Road

This inspection was carried out on 2nd October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 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 10/10/07

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 Deirdre Nash Key Unannounced Inspection 2nd October 2006 03:20 68 Bescot Road DS0000062047.V314314.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.V314314.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.V314314.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.V314314.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19/11/05 Brief Description of the Service: 68 Bescot Road is a care home that is owned and managed by Lonsdale Midlands Ltd. 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 service 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. 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. Fees for short stay during 2006/7 are £200 per night. Long stay weekly fees are not available or clear as the home has a ‘block contract’ with a local authority. 68 Bescot Road DS0000062047.V314314.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We looked at all of the information that we have received about this home since it was last inspected. Comments cards were sent out to relatives to get their views about it and five were completed and returned straight to us. We sent question cards to residents. None were returned to us. We will improve the way that we try to find out residents views in advance of an inspection in future. The Inspector called at the home without notice late afternoon, spoke with the manager, a member of staff, met three residents, looked around the first floor Unit and looked at records. The care of a sample of two residents was followed in this way to see if the home is providing a service that meets the national minimum standards. All the residents appeared to be well and well looked after although one person recently admitted to the home is having a big effect on everyone else there. The Inspector was advised that the presence of an unexpected stranger could further disturb him and so time spent with the residents and observing staff go about their work was limited during this visit. The home supports people of varied cultural and religious back grounds and communication difficulties. Five relatives who returned comment cards to us are generally satisfied with the standard of care offered by the home. One said, “My daughter stays at Bescot and I have always been completely happy with her care, completely happy with the conversations I have had with Jane [the Manager]”. What the service does well: Staff and managers get to know the regular short stay service users and long term residents well, learn how to communicate with them and treat them with respect. Contact with family is encouraged. Staffing levels are higher than average and people get a lot of individual attention. The house is kept clean and tidy and well decorated and it smells fresh. The manager is registered with us and is qualified to run this type of home. 68 Bescot Road DS0000062047.V314314.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. 68 Bescot Road DS0000062047.V314314.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.V314314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2,3, 4, 5 The outcome for this group is adequate. This judgement has been reached using available evidence including a visit to the service. The home has admitted a service user to its long-term care without a full assessment of his needs. Service users may be living in a home that cannot meet their needs. EVIDENCE: Two service users care files were sampled, one long stay resident admitted since the last inspection and the other a regular short stay service user. The short stay service user had a statement of purpose and service user guide in his file and a Community Care Assessment of his needs showing a threemonth review. The long stay resident had no assessment of need in his file and it is difficult to see how the home could make a decision to admit some one who’s needs had not been made known to them. The manager reports that this man was originally receiving a short stay service from them until his domestic circumstances changed last February, however this was only for two months. Observation confirmed the comments made by the manager and staff that this individual has made a significant impact on the quality of life at the home. Most freestanding objects including ornaments and the fire extinguishers have been moved out of the situation because he has thrown them at staff and other residents recently. 68 Bescot Road DS0000062047.V314314.R01.S.doc Version 5.2 Page 9 A full and up to date needs assessment should have been undertaken when his circumstances changed and the home should not have agreed to offer him a permanent place until it could confirm that those needs could be met. This issue was also raised at the last inspection. A requirement is made again to improve this practice generally and also to review his placement at the home against assessed needs specifically. If the home does not improve its admission practice the Commission may exercise its responsibility to take enforcement action for the safety of service users. Neither file contained any contract/written terms and conditions for care and accommodation. Service users and their representatives should be able to easily see what the service costs, who is paying for it and what is not included in the fees. A requirement is made to improve this. 68 Bescot Road DS0000062047.V314314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The outcome for this group is adequate. This judgement has been reached using available evidence including a visit to the service. Care plans vary in quality and do not sufficiently show how and where individuals can make their own decisions. Service users cannot be confident that their assessed and changing needs and personal goals are reflected in a written care plan. EVIDENCE: The file for a short stay service user looked at contain plans for daily care that covered a range of situations and fairly closely reflected the aims from the Community Care Assessment for the individual that the home has accepted responsibility to meet. Risk assessments are included. For the long stay resident there is a written for plan some areas of his life and care but most of these relate to care of medical conditions. These showed a three monthly review although one plan and risk assessment is for him taking a bath and staff report that he always takes a shower. Reviews should be meaningful and conducted with consultation 68 Bescot Road DS0000062047.V314314.R01.S.doc Version 5.2 Page 11 There were behavioural records and charts and records but these are reactive records and not a pro active plan for his physical, emotional, financial and social care and support underpinned by agreed written risk assessments. There is no evidence of planning in consultation with the service user or method of demonstrating how he is being supported to make day-by-day decisions where possible. Little progress has been made in practice in this group of standards since the last inspection in November 2005 where requirements were made. These substantially stand. 68 Bescot Road DS0000062047.V314314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 The outcome for this group is adequate. The home cannot show that all service users are getting access to a reasonable range of activity. Some service users spend much of their time confined to the house. EVIDENCE: The care plan for the short stay service user shows continuity with his usual educational programme and clearly outlines his leisure and sports interests. There is minimal information in the file of the long stay residents about social, leisure and educational interests or how the home is going about establishing these. There is an activity record completed daily by staff for this individual but for the week ending 01/10/06 little activity is actually described. For example ‘In house Activities’ is recorded for five and a half days that week but what these activities were is not specified. The resident spent Sunday 1st October watching television with other residents. The only day that he left the house according to this record was Friday morning when he went out for a drive. This resident cannot, according to staff, safely take himself out. 68 Bescot Road DS0000062047.V314314.R01.S.doc Version 5.2 Page 13 A requirement was made at the last two inspections to improve on the range of occupation and leisure activities available to residents. It remains only partially met. During the inspection one other resident was seen returning from a trip out for the afternoon with a member of staff. The manager reports that the home supports and encourages continued links with family and friends and there are letters on file to a relative written on behalf of a long stay resident to support this. Staff report that they are also supporting his interest in learning some Makaton signing so that he can communicate with another resident that he has befriended, this is not in his care plan however. There is some evidence from the daily records of this resident that daily routines are flexible in the home. Staff were observed using British Sign Language to communicate with a resident. A meal was cooking in the oven in the kitchen visited and residents were seen to be given hot drinks whenever they asked for them through the afternoon and early evening. There were few food or drink supplies in the fridge. The manager said that the weekly shopping would be done later in the evening as the events of the day had held it up. This was confirmed over the telephone to us next morning. 68 Bescot Road DS0000062047.V314314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19. The outcome for this group is adequate. This judgement has been reached using available evidence including a visit to the service. Some personal and health care is detailed and reviewed in individual care plans but many areas remain unaddressed. Service users may not be receiving personal support in the way that they prefer and require. EVIDENCE: The care plans looked at did address some personal care in detail. One file showed plans for personal hygiene and skin integrity, foot care and skin integrity and for maintaining body temperature for an individual with diabetes. Referred to above however, one of these plans at least is not accurately happening in practice and there are other areas of personal care that are not planned and risk assessed with and for this individual such as dressing, shaving, eating and drinking and psychological support through his bereavement. One relative said that her son often returns home not properly shaven and with the wrong clothes. This was discussed with the Manager who reports that it is being addressed. 68 Bescot Road DS0000062047.V314314.R01.S.doc Version 5.2 Page 15 Records show that specialist health practitioners are in contact with the home over individuals and the long term resident in the tracking sample returned from an out patients psychiatric appointment during the inspection. This is in response to his recently challenging behaviour. Notifications made to us over the past months show that mental health care specialist and social workers do visit the home on request to support service users. There is no record of routine health care appointments or a forward health care plan however. A requirement was made at the last inspection to improve this and it remains outstanding. The manager reported that another resident had been to the dentist that day. Comments from five relatives that returned cards to us confirm that service users are well looked after at the home. 68 Bescot Road DS0000062047.V314314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The outcome for this group is good. This judgement has been reached using available evidence including a visit to the service. The home has a well-publicised complaint procedure and staff are clear about their duty to report poor practice and concerns about service users well being. Good policies, procedure and staff training protect service users. EVIDENCE: The home has a clear written complaint procedure and this was seen posted in the lobby of the house. The manager reports that they have received one formal complaint this year and the service manager for the provider company investigated it. There was no record of this complaint in the home and there should be. A requirement is made to make records of all complaints or concerns raised by service users or other stakeholders in the home available at the home for inspection. Five relatives that returned comment cards all said that they have not had to make a complaint about the home. Access to kitchens, laundries, the office and the street doors are restricted to all residents and short stay service users by a coded lock that none of them can negotiate. The manager reports that individuals who live at the home or receive a short stay service from them are not able to safely use any of these rooms or be in the street unaccompanied. This was not recorded in either of the care plans inspected. 68 Bescot Road DS0000062047.V314314.R01.S.doc Version 5.2 Page 17 Any restrictions on liberty and choice and any form of restraint must be made only on the basis of a written risk assessment and recorded in the care plan of all individuals in the house that are affected by it and remain open to regular review. Whilst individual rights should be balanced against safety and the duty of care, the home must not operate blanket restrictions without accountability. A requirement is made to improve this. Staff spoken to are clear about their responsibility to report any concerns that they have about the well being of service users and residents or any allegations of bad practice or abuse to a manager. 68 Bescot Road DS0000062047.V314314.R01.S.doc Version 5.2 Page 18 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): 24, 30 The outcome for this group is good. This judgement has been reached using available evidence including a visit to the service. The home is well decorated, well maintained and kept clean and fresh. Service users live in a comfortable home. EVIDENCE: The home is clean, tidy, well decorated and maintained and smelled good. Furniture is good quality and there is plenty of natural light into the rooms. Referred to above the behaviour of one new resident had meant that most free standing objects have been removed in communal rooms but even so the house feels comfortable. Laundry facilities are separate to kitchens. There was no soap in the staff toilet on the day of inspection until the weekly shopping had been done in the evening. Staff must be able to properly wash their hands at all times to control the spread of infection. The manager must make sure that backup supplies of soap or hand wash are kept where they cannot be interfered with by service users. 68 Bescot Road DS0000062047.V314314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 The outcome for this group is good. This judgement has been reached using available evidence including a visit to the service. Staff are properly recruited, trained and supervised. Service users benefit from a professional approach to their care. EVIDENCE: Comments from staff and observation of them working with residents demonstrated the philosophy of care in the homes Statement of Purpose. Staff get to know residents and regular short stay service users well and treat them as individuals. All staff observed have good interpersonal and communication skills and responded to even very challenging residents warmly. The home has made good progress with over one third of care staff qualified at NVQ Level 2 and others enrolled on the programme. The home has four registered nurses. The roster for September 2006 shows average staffing levels of seven care staff during the day including one nurse and three care staff at night including one nurse. These levels are high but residents and many short stay service users require one to one attention much of the time around the house and all of the time outside of the house. Records show for example that bathing one service user requires two staff. 68 Bescot Road DS0000062047.V314314.R01.S.doc Version 5.2 Page 20 Staff work twelve-hour shifts with a one and a half hour break. This is a long time to be with very challenging people. Staff spoken to say that this provides a necessary continuity for service users and helps to reduce anxiety of shift changes. The staff turnover for the last 12 months has not been particularly high and the manager reports that sickness levels are not high. Staff are contracted to work for either 37.5 or 21 hours each week and the home does use agency and bank staff. There are currently four vacancies that are being recruited to. It is recommended that the length of staff shifts are shortened. Two personnel files were looked at. Certificates showed that staff undertook a lot of training at the end of 2005, for example non violent crises intervention and fire safety training. One file contained an NVQ Award at Level 3 certificate. Most staff undertook a very basic induction 18 months or 2 years ago. New staff should now be put through the Skills for Care Induction and staff should move through training within the Learning Disability Award Framework. Some evidence in records supported staff comment that there is an ongoing programme of one to one staff supervision. This is especially important when staff are caring for such challenging people over long shifts and for continuity of care for individuals. There are no application forms or CRB Disclosure certificates in staff files although the files contain a checklist sheet that has the certificate numbers. One file had references the other did not but had ‘two references’ ticked off on the checklist sheet. If the Provider organisation wishes to keep original records and proofs of staff fitness at a head office location it must agree this in writing with the Commission. Guidelines for the retention and storage of these required documents in on our website. A requirement is made to improve this practice for the protection of service users. 68 Bescot Road DS0000062047.V314314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43 The outcome for this group is good. This judgement has been reached using available evidence including a visit to the service. The home is well run with a clear internal and external management structure and managers have good contact with service users and their relatives. Service users live in a home that is run in their best interests. EVIDENCE: The manager is registered with us and qualified to run a care home of this type. She has made written notification to the Commission of incidents that affect the well being of the service users as she should and has made some progress towards meeting the requirements made at the last inspection but others remain not fully addressed. There is a deputy manager and two team leaders. 68 Bescot Road DS0000062047.V314314.R01.S.doc Version 5.2 Page 22 There is no evidence of any structured quality assurance system for the services provided by the home although the manager reports that she has very recently attended a quality assurance training event. The views of service users and other stakeholders should be regularly sought and the service subject to a continuous plan of improvement. Records show that fire safety equipment and installations are regularly tested and serviced and fire drills take place. The lift has been regularly inspected and serviced but comments from the engineers last report show that it is due for a ten-year service. There is no evidence that this has taken place. It must be arranged for the safety of everyone that uses the building. Certificates seen in staff files show that statutory health and safety training has taken place including manual handling and infection control. Two care staff cooked meals for the residents and service users on the evening of inspection, records show that the food hygiene certificate of one had expired. The manager should develop a training plan for statutory and other training. Foreward planning would ensure that basic health and safety training updates are routine. This was raised at the last inspection. The employers liability insurance certificate for the home has recently expired. The manager has confirmed that the cover has been renewed but the certificate had not yet arrived. She undertook to send a copy to us when it does. The Directors of the Provider company have recently changed but the Responsible Individual and senior managers remain the same. 68 Bescot Road DS0000062047.V314314.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 2 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 3 3 LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 x x 3 3 2 x 3 3 x 68 Bescot Road DS0000062047.V314314.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 YA2 Regulation 14 Requirement Timescale for action 15/11/06 2. YA3 14 The registered person must ensure that no admission is made without a full and up to date assessment of the persons needs. 15/11/06 The registered person must demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home, and to demonstrate it offers care based on current good practice and reflects relevant and clinical guidance. (Not met from last inspection compliance date 30/06/06) The registered person must 01/01/07 ensure that service users and their representatives have written terms and conditions for their care and accommodation including the fees to be paid and by whom. 1. Ensure that service user plans 30/11/06 cover all areas of assessed need and include all aspects of care: (emotional needs, healthcare, social needs, financial assistance, personal care etc.) DS0000062047.V314314.R01.S.doc Version 5.2 3 YA4 14 4. YA6 5 68 Bescot Road Page 25 2. To produce care plans in formats suitable for service users. 3. To ensure daily reports reflect goals identified in care plans. 4. To introduce effective evaluation, monitoring and reviews of service users plans which must be sufficiently detailed to reflect the changing needs of service users, and the objectives set. (Previous requirement remains partly met over last two inspections, last compliance date set at 30/06/06) 5. YA7 12 The home must demonstrate how daily routines and house rules promote independence, individual choice and freedom of movement, are flexible and service users are enabled to exercise control and are subject to restrictions only as agreed in the individual Plan and Contract. Individual working records should clearly set out residents preferred routines, likes/dislikes etc. (partly met from last inspection compliance date was 30/06/06) The home must demonstrate how daily routines and house rules promote independence, individual choice and freedom of movement, are flexible and service users are enabled to exercise control and are subject to restrictions only as agreed in the individual Plan and Contract. Individual working records should clearly set out residents preferred routines, likes/dislikes etc. (part met from last inspection compliance date 30/06/06) DS0000062047.V314314.R01.S.doc 30/11/06 6. YA18 12 30/11/06 68 Bescot Road Version 5.2 Page 26 7. YA9 13 To develop detailed individual 30/11/06 risk assessments with regard to all service users’ activities within the home and in the community, i.e. personal hygiene/bathing, use of transport, day care, use of kitchen/laundry equipment, access to community resources etc. and ensure each one is regularly reviewed and updated (previous requirement over two inspections partly met compliance date 31/03/06) The registered person must ensure that service users have planned opportunities for daily occupation and education. The home must evidence that service users 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 requirement over two previous inspections remains partly met last compliance date 30/06/06) The management must evidence that service users healthcare needs are being met, and procedures for routine screening 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 requirement over two inspections remains partly met compliance date 31/03/06) DS0000062047.V314314.R01.S.doc 8. YA12 12 30/11/06 9. YA13 12,16 30/11/06 10. YA19 12 30/11/06 68 Bescot Road Version 5.2 Page 27 11. YA20 13 12. YA22 22 13. YA23 13 14. YA23 13 15. YA34 19 16. YA42 13 17. YA42 13 The home should have a medication fridge and controlled drugs cabinet. There should be no gaps in medication administration records (Compliance date from last inspection 28/02/06 not inspected on this occasion) The registered person must ensure that a record of all complaints and concerns about the service is kept in the home and is available for inspection. Records of expenditure/income for service users monies should be regularly audited and balances checked. Staff should use their full names, rather than Christian names of financial records (compliance date from last inspection 31/01/06 not inspected on this occasion). The registered person must ensure that each and every restriction on liberty is accounted for individually in the care plan of each service user affected by it and regularly reviewed. The registered person must ensure that 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. The registered person must ensure that the 10-year inspection and service of the passenger lift is carried out. The registered person must ensure that staff health and safety competence training is kept in date. DS0000062047.V314314.R01.S.doc 15/11/06 15/11/06 15/11/06 15/11/06 30/11/06 30/11/06 30/11/06 68 Bescot Road Version 5.2 Page 28 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 YA30 Good Practice Recommendations Laundry procedures and a hand-washing poster should be displayed in the laundry rooms. Mops and buckets need to be clearly labelled for different areas of the home and when left to dry, mops should be inverted. 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. Care staff shifts should be reduced from twelve hours. All new staff should go through the Skills for Care Induction programme and progress to vocational training within the Learning Disability Award Framework. Develop a quality assurance system that includes consulting service users and other stakeholders in the home. Devise a matrix to plot statutory health and safety training on order to keep staff up to date. 2. YA32 3. 4. 5. 6. YA33 YA35 YA39 YA42 68 Bescot Road DS0000062047.V314314.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 68 Bescot Road DS0000062047.V314314.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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