Inspection on 10/10/05 for 7 Silverbirch Road

This inspection was carried out on 10th October 2005.

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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

7 Silverbirch Road 26/02/07

7 Silverbirch Road 11/05/05

7 Silverbirch Road 18/01/05

7 Silverbirch Road 25/08/04

7 Silverbirch Road 11/03/04

7 Silverbirch Road 04/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Silverbirch Road (7) Erdington Birmingham West Midlands B24 OAR Lead Inspector Joe O`Connor Unannounced Inspection 10th October 2005 11:20 Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 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 Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 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. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Silverbirch Road (7) Address Erdington Birmingham West Midlands B24 OAR 0121 382 1899 0121 382 1899 elcavanagh@aol.com 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) Birmingham Multi-Care Miss Emma Louise Cavanagh Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years. Completion of the Registered Managers Award by December 2004 Date of last inspection 11th May 2005 Brief Description of the Service: 7 Silverbirch Road is located in the Erdington area of Birmingham. It is close to the main Sutton Road, which has public transport links to Birmingham and Sutton Coldfield. The house is a traditional semi-detached property with space for off road parking. Limited off road parking is available. The facilities include entrance porch and foyer area, which houses the shaft passenger lift leading to the first floor. There is a spacious bathroom on the ground floor that is well equipped with aids and adaptations and a Jacuzzi bath. Laundry equipment is located in the ground floor bathroom. To the front of the premises there is a spacious lounge and to the rear is a dining room with patio doors leading via a ramp to a patio and large rear garden. There are four single bedrooms on the first floor all with individual colour schemes and matching bedding. One of the rooms has a double bed for service users who prefer more sleeping space. A shower room is located on the first floor with a toilet on the same landing. The service offers a respite care service for adults with a learning and physical disability. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a day. One service user was present at the start of the inspection but was unable to convey his views on life in the home. One service user was able to provide some verbal communication to express their views. Discussions were undertaken with one member of staff. A full tour of the premises was completed. Service users care plans and risk assessments were inspected. Staff recruitment and training records were examined and a number of health and safety records were also sampled. The Inspector had the opportunity to talk to the deputy manager. What the service does well: What has improved since the last inspection? The deputy manager stated that since the last inspection seven new staff had been recruited which staff commented has provided stability for the service users. She also stated that staff had received updated training in areas such as Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 6 first aid, food hygiene, and manual handling, with infection control training being booked during November. New staff were undertaking medication training. The manager had taken action to ensure service users’ homely remedies agreements had been reviewed by their respective doctor. New sofas and armchairs had been purchased for the lounge. One service user said that she liked them and found them comfy. The deputy manager stated the manager has been seeking quotes for new carpet in the lounge. 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. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 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 Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 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): 2, 3 Service users needs are assessed prior to admission to the service covering all aspects of their daily living activities. The needs of the current group of service users are met with staff demonstrating an understanding of their individual requirements. EVIDENCE: The service has not had any new admissions since the last inspection. The deputy manager stated that due to funding difficulties with the local authority there were no new placements being approved, other than those who are regular users of the service. One referral had been received and the information was written by the manager, which was detailed and referred to the prospective service user requiring 1:1 support in all aspects of their daily living activities. The referral had been made by a social worker and there was a letter from the manager providing the social worker with a breakdown of the costs for additional staff support. There were four service users staying for a short time and only one was able to provide verbal comments about life in the home. She commented, “ I like coming here, the staff are very nice”. “ I have a key to my bedroom”. Observations found that there were positive interactions between staff and service users. Service users were dressed in clothing that was well cared for. The atmosphere during this inspection was friendly and relaxed. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 Service users needs are set out in detailed care plans, but improvements are required in detailing service users’ specific likes and dislikes. Service users have risk assessments in place that ensure staff are aware of how service users are to be escorted and transferred. EVIDENCE: Three service users’ care records were examined at the time of this inspection. The care plans covered all aspects of service users daily living activities. Two care plans viewed provided evidence where the service users’ parents had provided written information regarding the service users daily routines. One example was that a service user needed to have their hair washed twice in the morning and afternoon due to a medical condition. The care plans also set out how staff should communicate with the service users such as the use of short sentences. The care plans while detailed did require some improvements with regard to service users likes and dislikes. For example two care plans stated that the service users enjoyed watching TV programmes and listening to music but did not say what particular programmes and performers they liked. The care plans also referred to service users requiring continence pads during the day and at Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 10 night but without details of what type and size that should be used. Risk assessments were in place including those for manual handling and escorting service users in the community. There were also risk assessments for the use of bedrails. These had been reviewed and dated since the last inspection. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 15, 16, 17 Interactions with service users are friendly and positive but must take into account their age and cultural requirements. Service users are able to maintain contacts with their families and maintain good relationships with each other and staff. Service users routines are not subjected to any unnecessary restrictions, but service users are not routinely offered keys to their bedroom. Service users are provided with a nutritious diet that promotes healthy eating and reflects individual cultural requirements. EVIDENCE: Service users did not have any restrictions with regard to accessing the home and their daily routine. Staff were observed to encourage service users communicate their needs verbally and in part through the use of sign language such as makaton. At the time of this inspection it was observed that one member of staff was interacting with a service user to music from a children’s’ TV programme. While it was evident the service user was receiving some benefit from the interaction, it would have been more appropriate had the music been more adult in its content and reflected his likes identified on the care plan that he liked Asian films and music. It was noted the care plans did not state whether service users had been offered a key to their bedroom, Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 12 although one service user stated she had one. In discussion with the deputy manager and from a sample of service users records service users are able to maintain contact with their family and other relatives. Relatives are encouraged to visit. There is an open visiting policy. Observations at the time of this inspection indicated there were good relation ships between service users and staff. An examination of service users care plans referred to service users being able to choose their own clothes when getting dressed. One care plan stated that one service user needed 1:1 support with cooking. Service users are provided with a varied nutritious diet. A record of meals eaten by service users is kept. Evidence seen from service users care plans found specific dietary requirements were known. One care plan sampled stated that the service user must have a halal diet, as he was a Muslim. Service users were observed to have tea and the atmosphere was relaxed with staff encouraging service users to choose drinks with their meal. The tea consisted of lamb chops, mashed potato, vegetables and gravy. The service user who required a halal diet was provided with a vegetarian option of quorn chicken style pieces. The meals looked well presented and the service users were enjoying it. The deputy manager was observed to assist one service user with feeding. She provided a quiet, gentle approach in encouraging the service user to eat and allowed him time to finish chewing his portions. The cupboards, refrigerator and freezer compartment were well stocked. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Service users receive flexible care and support that meet their individual requirements, nutrition assessments and those for the prevention of pressure sores have not been completed in full. Service users healthcare is appropriately arranged by the service promoting and maintaining good health. Medication management is to a good standard with some improvements needed. EVIDENCE: Service users care plans provided information regarding the GP they were registered with. When examining service users care plans there was information to confirm service users’ healthcare requirements were known. At the time of this inspection a service user was being visited by a District Nurse to undertake a blood test as part of her monitoring of diabetes. A communication record is maintained whenever the service user comes into the service for respite. This includes information given by relatives of any medication changes and whether the service user has to attend a medical appointment during their stay. The daily recording of service users referred to where service users had assistance with their personal care such as having a shower, bath or with shaving. At the time of this inspection the manager had partially addressed a requirement from the previous inspection for service users to have Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 14 assessments for nutrition and the prevention of pressure sores. Out the three service users records examined only one file contained these assessments. Manual handling assessments were in place and these had been reviewed since the last inspection. The management of medication was found to be good and the manager had put in place a list of staff trained to administer medication. This was a requirement from the previous inspection. A new BNF formula had been purchased. An examination of the Medicines Administration Records found there were no gaps in the recording but it was noted a number of crossings out had been made without any explanation for this. This practice must cease. The medication policy and procedure was still in need of updating to reflect current practice. This was a requirement from the previous inspection. The manager was taking action to address another requirement from the previous inspection for individual service users’ homely remedies agreements to be updated. Some had been returned and signed by their respective GP. It was good to see that staff had followed up an issue regarding one service user’s medication when they were admitted to the service. One of the items of medication was found to have a different name to that of the service user. The deputy manager had taken action to inform the service user’s family to say they could not accept what had been provided, despite the relative’s comments that it was for another member of the family but it was of the same dosage and times to be administered. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 There is an adult protection policy and procedure that is in the spirit of the D.O.H. Guidance No Secrets. Service users personal allowances are managed in a robust manner enabling a clear audit trail of individual expenditure and final balances. EVIDENCE: Standard 22 was not assessed but the outstanding requirement has been brought forward. Neither the service nor CSCI have received any complaints since the last inspection. The service has policy and procedure for adult protection and it was noted there was a new version of the multi agency guidelines published by Birmingham Social Care & Health. A procedure is in place for the use of physical intervention but this was found to require some amending to state that any use of physical intervention in an emergency must be notified to the CSCI via Regulation 37. It must also state that any planned means of physical intervention such as the use of bedrails must be discussed within a multi disciplinary group. Service users finances were examined during this inspection. Each service user has a written record of their personal allowances paid, monies spent and for what purpose, with a final balance that is checked and signed by two members of staff. Individual items of expenditure had a receipt attached to the balance sheets. Copies of the expenditure records are given to the service user or their relative. The monies are locked away securely and each service user has their own purse or wallet. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, 30 The premises are maintained to a high standard providing a clean, tidy and homely environment for service users. Service users bedrooms while comfortable and suitably furnished do not have lockable facilities. There is adequate shared space available that is comfortable to all service users. The premises have appropriate aids and adaptations including the toilets and bathrooms, maintaining service users independence and safety. Infection control practices while good need some improvement in ensuring service users welfare. EVIDENCE: The building was found to be clean, tidy and smelled fresh. Since the last inspection the manager had purchased new sofas and an armchair for the lounge which one service user commented was nice and comfy. There is a spacious lounge that is bright and airy with a TV, Video and DVD player. The dining room is located separately and provides a homely setting at mealtimes with photographs of service users and staff. There is a large well maintained garden that is accessible via a ramp and rails from the dining room. There is a jaccuzzi bathroom on the ground floor with a wash hand basin and toilet. Toilet facilities are also available on the first floor. There is a level access shower that is also the first floor. Service users have access to a range of Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 17 equipment to assist with moving and handling such as grab rails in the bathrooms and toilet with track ceiling hoists throughout the building. There is a passenger lift available that can accommodate wheelchair users. The bedrooms were found to be bright and airy with wash hand basin facilities available. The rooms were furnished to a good standard although it was noted there were no lockable facilities for service users to store their valuables. Suitable locks were fitted to the bedroom doors that would guarantee service users’ privacy but could be opened by staff in an emergency. The laundry is located in the bathroom but is not used when service users are having a bath. Appropriate arrangements are in place for the disposal of clinical waste. It was noted that staff were observed to be preparing food without wearing protective clothing. The light pull cord in the bathroom was dirty and in need of replacement. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35, 36 The organisation offers and provides training to all staff employed enhancing their development. Staffing levels have improved to provide service users with continuity of care, but the staff rota does not clearly state the actual shifts covered throughout the day. Staff recruitment records are generally maintained to an acceptable standard with some improvements required. EVIDENCE: Seven new staff have been recruited to the service since the last inspection. This has resulted in a reduction in the recruitment of agency staff. The deputy manager stated that there were two staff on duty during the evening, with one night waking staff member on duty. An examination of the staff rotas for the last four weeks did not provide clear information as to who was on duty as there were a lot of crossings out. The rota did not fully state the designation of all staff nor was there information as to the actual hours worked by staff and the manager. One member of staff’s name had been written on the rota by hand but it was not clear whether the person was a bank or agency worker. Appropriate staffing levels were being maintained at the time of this inspection. Staff spoken with at the time of this inspection demonstrated a good understanding around the needs of the service users in their care. Service users’ routines were known and respected. The deputy manager stated that the new staff that had been recruited were awaiting training for LDAF but the Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 19 trainer was currently on sick leave. Staff recruitment records included those who had recently been employed by the service. There was evidence in place of proof of identity including a passport, birth certificates and photograph. CRB checks, job application form, two references and declaration of fitness to work were also in place. It was noted however, there were no staff contracts of terms and conditions and a current job description. There was no documentation available to confirm that staff had undertaken an induction programme other than one for fire. The deputy manager stated that staff were provided with an induction handbook but was unable to find a copy and agreed to ask the manager to forward a copy of the handbook following this inspection. However, at the time of publication of this report a copy had not been forwarded to the Inspector. The recruitment records did not provide adequate confirmation that staff were receiving supervision every two months. Evidence was seen of training completed by staff in areas such as first aid, manual handling, basic food hygiene and adult protection. Future training being booked included infection control and diabetes awareness. It was noted that staff had received training in epilepsy and the use of rectal diazepam. The certificates examined stated that updated training was required for June 2005. So far this has not taken place and the manager must ensure this is addressed. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 40, 41, 42 There is an open, relaxed and friendly atmosphere benefiting service users and staff. The records are generally up to date for the safety of service users. There are a range of policies and procedures in place but these will need to be reviewed to reflect current practice. Service users health and safety is promoted and maintained with some improvements required. EVIDENCE: The Registered Manager was on annual leave at the time of this inspection and the inspection was undertaken with the deputy manager. It was her first time being part of an inspection and the deputy manager was co-operative and comments made were received positively. The deputy manager is currently completing qualification to NVQ Level 3. One member of staff commented that she enjoyed working in the home and that the management team were very supportive. The atmosphere was found to be relaxed and friendly which benefits the service users. Other staff members commented that having a full complement of staff had brought stability for the service users. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 21 Records maintained on the premises were generally up to date and locked away securely. The deputy manager stated that the manager and the Registered Provider were updating the policies and procedures but there was no evidence available to confirm this. Records with regard to health and safety were generally satisfactory with some improvements required. There was documented evidence that the fire alarm was being tested every week and the emergency lighting every month. Staff had received fire instruction and undertaken a drill since the last inspection. There was also evidence to confirm that the shaft lift had recently been inspected and serviced. The risk assessments for the prevention of fire and the premises had been reviewed. The main kitchen was clean and tidy. A daily record was being maintained for the refrigerator and freezer every day. The accident book was examined and it was good to see there were no significant accidents involving service users. However, it was noted that an entry relating to a service user with bruising had not been notified to the CSCI and an entry in the staff accident book referred to an incident where a service user had punched a member of staff. It was also noted an incident occurred when an intruder attempted to gain access to the premises and this too had not been notified to the Commission. Standard 43 was not assessed in depth. The service did have adequate employers liability insurance certificate but this was found not to be on prominent display on the premises. Standard 39 not assessed but outstanding requirement has been brought forward. Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score N/A 3 3 N/A N/A Standard No 22 23 Score N/A 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 N/A 3 N/A Standard No 24 25 26 27 28 29 30 STAFFING Score 3 N/A 2 3 3 3 3 LIFESTYLES Standard No Score 11 2 12 N/A 13 N/A 14 N/A 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score N/A N/A 2 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Silverbirch Road (7) Score 3 3 2 N/A Standard No 37 38 39 40 41 42 43 Score N/A 3 N/A 2 3 3 N/A DS0000016990.V252411.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(1)(2) Requirement Timescale for action 10/12/05 2 YA11 3 YA16 4 YA18 5 YA20 The Registered Person must ensure service users’ care plans specify service users’ likes and dislikes with regard to their leisure interests. They must also state what kind of continence pads are to be used. 12(3)(4)(a) The Registered Person must (b) ensure service users receive interactions from staff that reflect their age and cultural requirements. 12(3)(4) The Registered Person must ensure service users are offered a key to their bedrooms. Any reasons why service users are unable to have one must be subject to a risk assessment and the decision documented on their care plan. 12(2) The Registered Person must ensure all service users care records include assessments for nutrition and prevention of pressure sores. 13(2) The Registered Person must ensure the Medicines Administration Records must clearly state reasons for crossed out entries. DS0000016990.V252411.R01.S.doc 10/12/05 10/12/05 10/11/05 10/11/05 Silverbirch Road (7) Version 5.0 Page 24 6 YA26 16(2)(c) 7 8 YA30 YA30 13(3) 13(3) 9 YA33 18(1)(a) 10 YA34 17(2) 19(1)(a,b) Sc2 18(1)(a)(c) 18(2) 11 12 YA35 YA36 13 YA39 24(1) The Registered Person must ensure service users are provided with lockable facilities in their bedrooms. The Registered Person must ensure staff wears protective clothing when preparing food. The Registered Person must ensure the light pull cord in the ground floor bathroom is changed, as it is dirty. The Registered Person must ensure the staff rota clearly states the following: - Staff names - Person in charge - Hours worked - Identifies designation of job - Days/Nights - Handovers - Must include hours of whether rota actually worked. Managers hours would normally be more than thirty less then forty eight per week (excluding on call), if undertaking care and management tasks. This must be denoted. The Registered Person must ensure staff recruitment records include Current job description Statement of terms and conditions. The Registered Person must ensure training in epilepsy awareness has been updated. The Registered Person must ensure staff records provide clear evidence to confirm the frequency of staff supervision. The Registered Person must establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided. A system is being developed to ensure a system of continuous self monitoring, using an DS0000016990.V252411.R01.S.doc 10/01/06 10/10/05 31/10/05 10/12/05 10/12/05 10/11/05 10/11/05 10/12/05 Silverbirch Road (7) Version 5.0 Page 25 14 YA40 NMS CH YA A2 15 YA42 13(4) 37(1) objective, consistently obtained and reviewed through a verifiable method (preferably a professionally recognised quality assurance system.) This standard not assessed. Outstanding Requirement has been brought forward. Timescale 31 March 2005 & 11 August 2005 not met. The Registered Person must 10/12/05 ensure that its policy and procedure are reviewed to reflect current practice. Outstanding Requirement. Timescale 11 August 2005 not met. The Registered Person must 10/11/05 ensure that any incident affecting the welfare of service users is notified to the CSCI without delay. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Birmingham 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 Silverbirch Road (7) DS0000016990.V252411.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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