Inspection on 11/05/05 for 7 Silverbirch Road

This inspection was carried out on 11th May 2005.

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

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

Other inspections for this house

7 Silverbirch Road 26/02/07

7 Silverbirch Road 10/10/05

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 7 Silverbirch Road Erdington Birmingham B24 0AR Lead Inspector Joe OConnor Unannounced 11 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Silverbirch Road, 7 Address 7 Silverbirch Road Erdington Birmingham B24 0AR 0121 382 1899 0121 382 1899 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Birmingham Multi-Care Miss Emma Louise Cavanagh Care Home 4 Category(ies) of Younger Adults, Learning Disability, Physical registration, with number Disability of places Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. 2. Completion of the Registered Managers Award by December 2004. Date of last inspection 18 January 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 services to Birmingham and Sutton Coldfield. The house is a traditional semi detached property with space for off road parking. Its external features are similar in design and structure to that of its neighbours and its purpose as a care home is not distinguishable. 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 equiped with aids and adaptations and a jacuzzi bath. Laundry equipment is located in the ground floor bathroom. To the front of the house there is a spacious lounge and to the rear is a dining room with patio doors leading via 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 home offers a respite care for adults with a learning and phsyical disability. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was unannounced and took place over one day. Three service users were present of which two conveyed their views on life in the Home. Discussions were also undertaken with two members of staff. A limited tour of the premises was undertaken. 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 opportunity to talk to the Registered Manager and Service Manager. What the service does well: What has improved since the last inspection? The manager had successfully achieved qualification for the Registered Managers Award and had addressed all but one of the previous inspection requirements. Staff have received physical intervention training and the protection of vulnerable adults. Staff members said that they found this training arranged by the manager, to be beneficial and enable them to reflect on their current practice. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 6 Since the last inspection the manager has put in place a periodic reviews of service users, their families and other representatives. Views of the level of satisfaction about the care were shown to the Inspector. Positive relationships between staff and service users were further demonstrated through the positive daily recording undertaken by staff. Staff spoke of the manager in a positive manner, feeling supported and finding her approachable and open to new ideas in improving the service users quality of life. Service users needs are appropriately met, demonstrated through a sample of service users records and from discussion with the manager. The manager has greatly improved staff recruitment records with the addition of evidence of training and qualifications. A training plan is in place that identifies future training needs for all staff. Health and safety issues were found to be addressed by the manager that was satisfactory with evidence of up to date inspection and testing of fire fighting equipment and electric hoists. 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 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 5 Services users needs are assessed prior to admission to the Home covering all aspects of their daily living activities. The needs of the current user group are being met through the maintenance of detailed care records and with a committed staff team who have knowledge of individual needs. Service users have a statement of terms and conditions that informs them of what they are paying for when they are admitted to the Home. EVIDENCE: Service users records sampled at the time of this visit confirmed that assessments are undertaken prior to admission. Three of the service users records contained assessments completed by the manager that were found to be detailed covering all aspects of the individual circumstances. There was also evidence to confirm that assessments and initial care plans had been completed by social workers prior to admission. There were three service users staying for a short time and provided the following comments about life in the home. One service user said “ This is a much better home compared than the one I used to stay in because the staff their didn’t listen to me.” “The staff here look after me well”. Another service user stated, “ I like coming here the staff are friendly and they listen”. “ They always ask me what I would like to do.” Observations found that there were positive interactions between the staff and service users. Service users were observed to be dressed in clothing that was Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 9 well cared for. There are detailed records in place that clearly set out how the needs of service users are to be met. All three service users’ records examined had contracts or statements of terms and conditions in place. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 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 standard(s) 6, 7, 9, & 10 How service users needs are to be met are set out in detailed care plans. These cover service users individual likes and dislikes and how these should be met. However the care plans did not provide evidence as to whether service users and their representatives had been involved in their development. Staff encourages service users to make decisions with regard to their daily routine on a day to day basis. Service users have risk assessments in place that ensure staff are aware of how service users are to be escorted and transferred. Staff protects service users confidentiality and only share information with the service users’ consent and through the secure storage of records in the home. EVIDENCE: Each service user has a detailed care plan that covers all aspects of their daily living. The care plans contained specific details about specific likes and dislikes. For example one care plan sampled stated that one service user preferred to have a bath rather than a shower and this was confirmed when talking to the individual service user concerned. The same care plan referred to the service user requiring treatment for Diabetes Mellitus that required the use of insulin. The guidelines on the care plan set out when the district nurse visited and to administer the insulin and the type of equipment to be used. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 11 Another care plan sampled referred to details of communication to be used for one service user through the use of pictures and symbols. At the time of this inspection the care plans were being up dated by the manager. While it is acknowledged that the care plans were detailed there was no evidence to confirm whether the service user had been involved in their development and review. 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 but these did not have any dates of when they were completed. In discussion with service users and staff it was evident that service users are encouraged to make choices about their daily lives. Two service users said that staff would show them what was available for lunch and tea and when they go to bed and get up. While there are no formal service users meetings in place the size of the home means that decisions are made in a relaxed informal atmosphere. As one member of staff commented its a home where everyone is part of a family. Staff demonstrated a good understanding and awareness of issues around confidentiality highlighting the need for service user consultation and when sharing personal information and this should only be on a “need to know basis.” Service users records were found to be locked in a secure facility. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 16, &17 Service users have access to leisure activities in the community and also receive organised activities provided by other agencies. Service users routines are not subject to any unnecessary restrictions subject to their individual risk assessment. Service users are provided with a nutritious varied diet that promotes healthy eating. EVIDENCE: Service users did not have any restrictions with regard to accessing the home and their daily routine. They were able to access all parts of the home. Staff encourages service users to communicate their needs. Two service users stated that they were able to get up and go to bed when they wanted. Staff also confirmed that there were no unnecessary restrictions in place and that the service users were free to do what they pleased. There was written evidence in place to confirm that service users have access to daytime activities one by a private day service, the other provided by the local authority. At the time of this inspection a service user asked a member of staff if they could go out for lunch and this request was granted. Later the service user stated they went to the local shopping area and had lunch with a member of staff. The service user also stated she had a nice time Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 13 going out. A sample of service users daily recording found that service users are provided with opportunities to go out in the community including the local pub, cinema in Sutton Coldfield and restaurants. Service users are provided with varied a varied nutritious diet and that a record is maintained of the meals eaten by service users. It was evident from an examination of service users’ care plans that specific dietary requirements are recorded and followed. Service users were observed having tea and the atmosphere was found to be relaxed with one service user being assisted with appropriate equipment such as a non slip mat and plate guard. There is a well stocked cupboard and refrigerator of food items. Specific dietary requirements are addressed. A service user spoke about the need to have “no sweet” food because of her diabetes and there was evidence on that individual’s care plan that these dietary requirements had been recorded. The food being provided at teatime was well prepared and the service users were observed to enjoy their meal. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 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 standard(s) 18, 19, & 20 Service users receive flexible care and support that meets their individual requirements. Service users healthcare is appropriately arranged by the home promoting and maintaining good health. Medication management in the home is good with some minor improvements required. EVIDENCE: A sample of service users’ care plans found that service users are registered with a GP. It was also evident from the records seen relationships are kept with other multi-disciplinary services such as Speech and Language Therapist, Community Nurse, Consultant Psychiatrist. An examination of care plans found that specific healthcare requirements were known. One care plan had identified that one service user had epilepsy and that any seizures had to be recorded on a chart. There was evidence to confirm that staff were recording on the charts and identifying the type of seizure that had occurred. As stated previously there was information on a service users’ care plan as to how their diabetes was being treated. Information with regard to cultural requirements had been recorded on one individual’s care plan about their religion and language. Service users must have assessments in place that identify their nutritional needs and the prevention of pressure sores. Medication management was found to be good, although there are number of issues that need to be addressed that were discussed with the manager who was receptive to the comments made. First there needs to be a list of staff Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 15 signatures of those staff administering medication to service users. It is recommended that an up to date BNF is purchased and the medication policy and procedure will require updating to reflect current practice including a statement that the CSCI must be contacted where medication errors have occurred. Staff have received accredited medication and specialist training in epilepsy awareness and the use of rectal diazepam. Written protocols are in place for service users who need to have rectal diazepam. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 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 standard(s) 22, & 23 There is a complaints procedure which should be available to service users in a suitable pictorial/ symbol format. There is an adult protection policy and procedure that is line with 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: Neither the provider nor the CSCI have received any complaints since the last inspection. A complaints procedure in place that is available in audiotape and in different languages. However, work is required to provide a procedure that is available in a suitable pictorial format. Since the last inspection staff working in the home had received training in physical intervention. This was confirmed by two staff members and in examining staff files. Staff stated that the training was beneficial and made them reflect more on their own practice. The manager stated that they were waiting for certificates to go on the files. There is a policy and procedure with regard to adult protection and physical intervention. However, the policy and procedure for physical intervention will require updating to state that the CSCI must be informed where physical intervention had been used and that any planned means of physical intervention must be discussed within a multi disciplinary service group. Service users financial records 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 balance sheets are given to the service users when they return to their own home. The monies were found to be held in a secure facility. Each service user have their monies kept in their own purses or container. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 28, 29, & 30 The premises are maintained to a high standard and provide a clean, safe environment for service users. Appropriate aids and adaptations are in place that maintain service users’ independence and safety. Staff observe appropriate infection control practices that ensure service users welfare is maintained. EVIDENCE: The Home was found to be clean, tidy and well maintained. Two service users told the Inspector that they thought the home was nice and clean and liked the colours of their bedrooms. Service users have access to a range of equipment to assist with moving and handling such as grab rails in the bathrooms and track ceiling hoists throughout the building. A passenger lift is also available that can accommodate a wheelchair user and a member of staff. Access is available via a ramp. There are appropriate arrangements in place for the disposal of clinical waste. The laundry is located in the bathroom but this is not used when service users are having a bath. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, & 35 The organisation offers and provides training to all staff employed to enhance their development. Staffing levels do not always provide service users with a continuity of care. Recruitment records for staff are maintained to the requirements of Schedule 2 Care Homes Regulations 2001. A robust recruitment policy and procedure is in place that protects service users. The interactions between staff and service users were positive providing a relaxing environment. EVIDENCE: Two members of staff demonstrated a clear understanding of the needs of the service users in their care. Service user’s routines were known and respected. Requirements from the previous inspection for the completion of physical intervention training and adult protection had been addressed. Staff spoken with stated that since completing the training they had a better understanding around the issues of abuse and felt able to challenge poor practice. Four staff files were sampled and there was evidence that staff had received training in areas such as health and safety, fire safety, manual handling, adult protection, accredited medication and specialist training in areas such as epilepsy and the administration of rectal diazepam. A training plan was in place and it was noted that updated training in areas such, as food hygiene were booked for June 2005. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 19 Additional training is being planned for infection control and awareness of autism. A representative from the organisation who was visiting the home stated that a new induction programme was being introduced. Staff recruitment records were found to meet the requirements of the regulations and there was evidence in place of proof ID, two references, job application form and CRB checks. Evidence of qualifications was also on the files. Staff files sampled found that four members of staff were qualified to NVQ Level 2 and one is qualified to NVQ Level 3. Staffing levels have been difficult to maintain and this was noted when sampling the staff rota for the previous four weeks. Three vacancies are being carried and the manager had recently shortlisted twelve applicants for an interview following this inspection. A team of bank staff is available and agencies are used to fill in where shifts need to be covered. The manager admitted that she had to cover some shifts. It is acknowledged there have been difficulties in recruiting staff and it was evident that the manager is robust in her approach in ensuring correct procedures are followed when recruiting for staff. Two examples were provided where the manager refused to appoint prospective staff due to unsatisfactory references of one individual and because the other applicant did not have adequate immigration status. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 41, 42, Service users live in a home that is run by a competent manager. There is an open and relaxed atmosphere that benefits service users and staff. The records were 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 and to reflect current practice. Service users do not have enough involvement in commentating on the care and support they receive. Therefore further improvement is required in developing an effective quality assurance system. EVIDENCE: The manager demonstrated an awareness and detailed knowledge of the service users in her care. It was evident from talking to her that she cares a great deal for the service users and is always looking at different ways to improve the service they receive. During this inspection relatives for one service user, arrived at the home to pick up some personal items. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 21 Observations at the time found that the manager was working with the relatives to identify a simple means of communication and demonstrated openness and listened sensitively to their concerns. She has a wide range of experience working in the area of learning disability. The manager has achieved qualification to the Registered Managers Award in December 2004 and a copy of the certificate was available to confirm this. Two service users stated that they would be able to tell the manager if they were unhappy about anything and felt they would be listened to if there were any concerns. Service users benefit from a relaxed homely atmosphere and this was evident when staff were observed to be talking to the service users when watching a TV programme. Staff stated that the manager was very supportive and that she was always available to provide assistance. There were minutes of staff meetings, which are held every month. Staff did express some concerns with regard to the staffing difficulties but felt this was not the fault of the manager and acknowledged she had difficulties in recruiting the right person and had confidence in her. A representative from the organisation visits the home on a monthly basis and reports from her visits are available for inspection. It was noted hat although there was evidence of the service users who had been spoken to there was no record of what comments they had to make about the care and support they were receiving. Satisfaction surveys had been completed by service users’ relatives and representatives. Since the last inspection and those sampled were very positive. Copies had been sent out to professionals such as social workers but unfortunately no response had been received. Additional work is required to ensure satisfaction surveys are made available to staff so that they have an opportunity to comment on the care being provided with regard to the running of the home. Records maintained in the home were generally found to be up to date and locked in a secure facility. Records with regard to health and safety were found to be satisfactory. There was documented evidence that the fire alarm was being tested on a weekly basis the emergency lighting had been tested every month. Staff had undertaken a fire drill and fire training since the last inspection. Evidence was in place to confirm that the hoists had been inspected and serviced. There was written evidence that the equipment for gas, electric, lifts and fire fighting had been tested and serviced. A risk assessment is in place for the prevention of fire and this had been reviewed since the last inspection. The main kitchen was found to be clean and tidy with a daily record being maintained for the refrigerator and freezers. A daily occurrence book is in place and the accident book was examined and found to be recorded appropriately. It was good to see that there are no significant numbers of accidents involving service users with only two recorded since the last inspection. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 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 x 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 3 Standard No 31 32 33 34 35 36 Score x 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Silverbirch Road, 7 Score 2 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x 3 2 x E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 15(1)(2) Requirement Care plans must have documented evidence that service users were involved in their development and review. Risk assessments for the use of bedrails must be signed and dated. The home must ensure that it develops assesments in the following areas Nutrition & Prevention of Pressure Sores. The home must ensure that there is a list of trained staff signatures on the Medicines Administration Records (MAR charts) It must also obtain an up to date edition of the BNF. This is now a Good Practice Recommendation Please Refer to Page 27 The medication procedure must be reviewed and updated to reflect current practice. The home must ensure that the complaints procedure is in an accessible format for service users. The home must ensure it maintains minimum staffing levels. Timescale for action 11 July 2005 11 June 2005 11 July 2005 2. 3. 9 18 13(4) 12(3)(4) 4. 20 13(2) 11 July 2005 5. 6. 20 22 13(2) 22(1) 11 July 2005 11 August 2005 11 August 2005 Page 24 7. 33 18(1)(a) Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 8. 9. 39 39 26(1) 24(1) 10. 39 24(1) 11. 40 NMS For Care Homes Younger Adults Appendix 2 Service users views must be recorded during the service managers monthly visits. Satisfaction surveys must be developed for staff so that they are able to contribute their views on life in the home. The manager 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 objective, consistently obtained and reviewed verifiable method (preferably a professionally recognised quality assurance system) This standard partially met and remains outstanding from timescale 31 March 2005. The home must ensure that its policies and procedures are reviewed and updated to reflect current practice. 11 June 2005 11 July 2005 11 August 2005 11 August 2005 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 20 Good Practice Recommendations It is recommneded that the home purchases an up to date BNF. Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor,Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Silverbirch Road, 7 E54 S16990 7 Silverbirch Road V227207 110505 Stage 4.doc Version 1.30 Page 26 - 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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