Inspection on 22/08/05 for 73 Beech Road

This inspection was carried out on 22nd August 2005.

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

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

Other inspections for this house

73 Beech Road 15/12/08

73 Beech Road 16/08/06

73 Beech Road 27/01/06

73 Beech Road 02/03/05

73 Beech Road 29/09/04

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 Beech Road (73) 73 Beech Road Wednesbury West Midlands WS10 9NR Lead Inspector Jayne Fisher Announced 22 August 2005 nd 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. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beech Road (73) Address 73 Beech Road Wednesbury West Midlands WS10 9NR 0121 502 1418 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) Pioneer Care Limited Sandra Horsley Care Home 3 Category(ies) of LD - Learning Disabiltiy (3) registration, with number of places Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Service user accommodated at the home may also be DE. This will remain until such time that the current service users placement is terminated. Date of last inspection 2nd March 2005 Brief Description of the Service: 73 Beech Road is a small care home in the heart of a residential area near to Wednesbury town centre. The home is close to shops and local amenities, and close to a public transport route. The home is registered to provide care for three people with learning disabilities and is owned by Pioneer Care Ltd.The home is set out on two floors providing single bedrooms, toilet facilities and an office on the first floor: one lounge, a shower room and toilet, and a dining/kitchen on the ground floor. There is car parking on street, and a front and rear garden. The home has recently installed a stair lift within the home. Services on offer include a key worker system, accessing community based healthcare and social resources, and a range of in house events with other Pioneer Care homes Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted between the hours of 9.30 a.m. and 4.00 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: case tracking, formal interviews with the manager, the home leader and three members of staff. There was also a brief tour of the premises. 73 Beeches Road is registered to provide care for three adults with learning disabilities and associated complex needs such as communication difficulties. One resident was at home during the inspection and another returned home from a day centre shortly before completion of the inspection process. Formal interviews were not possible therefore the inspector relied upon body language and observations of interactions between staff and residents. A number of records and documents were examined. Other information was gathered prior to the inspection which included the pre-inspection questionnaire, an action plan submitted by the home following the last inspection, feedback from a relative and a social worker. A relative also visited during the inspection to talk to the inspector. The inspector was made to feel very welcome and would like to thank service users and staff for their assistance and co-operation during the visit. What the service does well: New service users are only admitted to the home following a full assessment which is undertaken at a number of visits. This ensures that existing residents meet and get to know the new resident, and that management are confident that they can meet needs. There is an efficient care planning system. Residents are able to participate in this process through an essential life style planning approach which means that they can exercise control over the service they receive and that they are able to make their preferences known about how they wish to be supported by staff. There are lots of opportunities for personal development for residents through attendance at day centres, college placements, stimulating activities provided by staff and community outings. This year residents are going on two holidays one of which is abroad. There was lots of positive interaction observed between staff and residents, with residents smiling and laughing in response to staff voices and presence. Staff fully support residents to maintain links with their relatives. The environment is homely and comfortable promoting a family type atmosphere. There is a strong commitment to providing new staff with training before they commence work so that they already have the skills to meet the needs of residents. Staff are well supported by management who Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 6 they can approach when needing advice thereby residents benefit from a well run home with competent and trained staff. A visiting relative commented that: “It’s like their own home here. They can go out as much as they want. If I had any concerns I would find it easy to approach any member of staff”. Positive comments from a social worker included “this home has a wonderful relaxed environment when entering and visiting. Staff are always approachable and friendly, a pleasure to have the opportunity to visit regularly”. 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. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 4 and 5 New service users are admitted only on the basis of a full assessment and have an opportunity to visit the home on a number of introductory visits thereby enabling them to make an informed decision about whether to move there. Terms and conditions of occupancy require slight expansion in order to ensure service users have been supplied with all of the information about their entitlements. EVIDENCE: Since the last inspection there has been a new admission to 73 Beech Road. Discussion with management and examination of documentation confirmed that a full assessment had been undertaken by the manager and appropriate documentation had been obtained from the placing social worker. It was pleasing to see that the manager had written to the prospective service user confirming that the home could meet their assessed needs as required by the Care Homes Regulations 2001. The National Minimum Standards were exceeded with regard to the introduction of the new service user to the home. Assessments and visits were undertaken a full two months prior to placement. There were a number of visits to the home to assess compatibility with existing residents and the environment which included overnight stays. The organisation has produced documents specifically for the purpose of recording introductory visits which is commendable. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 9 All service users have a contract/statement of terms and conditions of occupancy. These are detailed documents and generally comply with the requirements of the National Minimum Standards 5.2. For example, they are signed by the Registered Manager and service user (and/or advocate). However, one resident’s contract did not contain details of additional charges and this needs to be addressed. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 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 and 9 There is a very good care planning system which includes an essential life style approach. As a result service users have been given an opportunity to participate in care planning and make their wishes and aspirations known. Service users are assisted to make decisions about their lives through this process, although management of finances requires slight expansion. There is a good risk management system only minor improvement is necessary in order to ensure that all risks are examined. EVIDENCE: All service users have care plans in place which cover a wide selection of goals and objectives including personal hygiene, health care needs, nutrition, social activities and behaviours. Care plans examined contained excellent communication packages thereby giving staff detailed descriptions of how to communicate with residents. Each service user has an essential lifestyle plan. These are very comprehensive giving the reader extensive details of residents’ preferences regarding their daily routines and how they wish to be supported. There are monthly evaluations of care plans and regular review meetings to which relevant professionals and relatives are invited. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 11 Feedback obtained from a social worker confirmed that care plans are regularly reviewed and that staff demonstrate a clear understanding of the resident’s needs. During interviews staff gave good responses as to how they support residents to make decisions which corresponded with details in individual care plans. For example, using body language and facial expressions to determine preference. Two residents have independent appointees to assist with management of their finances. A third resident has their own bank account which staff assist and support the resident to access. Each care plan contains a ‘financial agreement’ which contains the resident’s (and/or advocate’s) consent to staff support in management of personal allowance and benefits. As discussed, it would be beneficial for a written care plan to be established with regard to the one resident who is the exception, and who has their own bank account. Details should be included as to how this support is given and procedures which are in place to minimize risks of financial abuse. Each care plan has a corresponding risk assessment which is scored using a rating system. Details of the rating system is contained within case files for reference. There was only one area which requires slight improvement and this is in respect of the risks related to wheelchair use. New risks which have been identified by the Medicines and Healthcare Products Regulatory Agency in January and April 2005 need to be considered and included in risk assessment management. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 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) 11, 12, 13, 14, 15 and 16 Staff encourage service users to maintain and develop social, emotional, communication and independent living skills and as a result they are provided with lots of opportunities for personal development and stimulation. Staff support residents to maintain important family links thereby enriching their lives. Daily routines promote independence which ensures residents’ rights are respected. EVIDENCE: All residents have care plans in place which identify goals and objectives with regard to daily living skills and social activities. These are detailed and comprehensive. Two residents attend day centres and/or college placements during the week. Management report that they are still seeking an appropriate day centre placement for the third resident. Interviews with staff, examination of care plans and observations on the day, confirmed that there are a number of stimulating and appropriate activities undertaken by this resident which is very much user led. There are no structured activity programmes as management use the comprehensive care plans as a guide. Staff report that they are given instructions on a daily basis in respect of which activities to Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 13 undertake. On examination daily reports and monthly evaluation forms do not always contain information to confirm that goals and objectives identified in care plans for example with regard to independent living tasks. (See further comment in standard 41). There are regular outings in the community. For example during a ten day period one resident had gone on shopping trips to three different town centres (as well as attending a daily day centre). Another resident had enjoyed going out for lunches and visiting local shops. Residents participate in social activities and are able to follow their own hobbies and pursuits. For example one resident likes to listen to music, another has favourite television soaps and one resident likes to sit in the garden and participate in gardening by watching staff tend to the flowers and lawn. There are regular holidays; the main holiday is funded by the organisation. Care plans contain information as to how residents are supported to maintain family links. Some residents are enabled to visit their families and go to their former family home. A relative who was interviewed stated that she was always made to feel very welcome and could see her relative in the privacy of their bedroom if they wished. Any restrictions upon residents’ daily choices are negotiated and recorded. For example, with regard to staff opening mail on service users’ behalf. Care plans contain residents’ preferred form of address. There was lots of positive interaction observed between staff and residents. Bedroom doors do not have suitable locking mechanisms. This still needs to be discussed with residents and their advocates and outcomes recorded in care plans. As discussed, ideally bedrooms should be fitted with appropriate locks upon becoming vacant. This was a recent opportunity with the advent of a new resident which was not taken up. However, management stated that as this service user may be able to operate such a device this would be looked at. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 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) 19 The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis; slight improvements are necessary (mainly in recording/monitoring), in order to further promote good health care practice. EVIDENCE: There was evidence that all residents have received regular health care check ups and medication reviews. Service users are weighed on a weekly basis and records maintained in their daily diaries. All residents have received ophthalmology, audiology and dental checks. Upon admission the new resident had recently been supported by staff to access the appropriate checks by relevant health care professionals. Records of appointments in respect of chiropody are not always being kept up to date. A six monthly dental check up had been cancelled by management as they were looking to source a home visit would be less distressing for residents. This is commendable, however, records should have been maintained of this action. In early August 2005 one resident’s daily reports identified that a member of staff had concerns regarding broken skin on a pressure area and instructed other staff to monitor. There was no further reference to this or evidence that it had been monitored in the daily reports. Interviews with management Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 15 confirmed that monitoring had been on-going and that there was no cause for concern. However, this should have been fully recorded. Case files contain information regarding screening for potential complications such as testicular and breast cancer, mainly by the attendance at an annual well person clinics. One resident should have attended a twelve monthly check in February 2005 however on further discussion this had been overlooked and management stated that this would be actioned. As discussed care plans must be expanded to include formal procedures as to how staff monitor through visual observations whilst carrying out personal care tasks in relation to this aspect of health care which would supplement the annual attendance at a well person clinic. Discussion of invasive screening techniques also took place; management should discuss this further with the General Practitioner due to the lack of capacity to consent, and record outcomes in individual care plans. As requested the organisation has reviewed and expanded the medication policy. Keys to drug cupboards are now kept secure. Through case tracking it was ascertained that advice had recently been sought with regard to one resident who had suffered diarrhoea. However, staff had accepted the advice given by the receptionist regarding treatment (an over the counter remedy Imodium). As discussed with management, any health care issues must be discussed directly with the appropriately qualified medical practitioner. At present the home does not have a household remedy policy which has been ratified by the General Practitioner and this needs to be addressed if the home is going to continue to use household remedies. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 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 and 23 There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon. The home is making good progress in ensuring policies, procedures and practice, safeguard from service users from abuse. EVIDENCE: The home has a comprehensive complaints policy which has been produced in a pictorial format. Feedback from a relative confirmed that they were aware of the complaints procedure. The organisation has recently updated the vulnerable adult abuse procedure to include details of the Protection of Vulnerable Adult (POVA) scheme. The new procedures states that staff should familiarise themselves with the POVA guidelines but unfortunately these could not be located. There is a copy of the Local Authority Adult Protection procedures and Department of Health ‘No secrets’, on the premises as is good practice. Some staff have received vulnerable adult abuse awareness training and new staff are to receive training in the near future. Staff who were interviewed competently and correctly described how they would deal with any incidents of abuse. Staff support residents to manage their finances. On examination there are good records maintained of all income and expenditure with two staff initials for all financial transactions and receipts obtained. A sample of monies balanced accurately with records maintained. At the last inspection it was established that occasionally residents would pay for their own meals if on an outing in the community. This is a replacement Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 17 meal and not over and above what is included in the basic contract fee. Management were asked to discuss this with funding authorities and service users’ advocates and to establish a formal procedure. Staff have accordingly obtained written confirmation from relatives that they have no objection to this practice. Social workers have also been contacted and raised no concerns, however discussions must be fully recorded. A formal procedure has yet to be devised. The practice was once again discussed in order to determine how decisions are made in respect of this aspect. It was stated that meals were paid for by resident if the weekly food shopping budget had already been exceeded. It came to light that extraneous items such as stationery as also paid for out of this budget. The budget must also therefore be reviewed as part of this requirement to ensure that it is of a sufficient amount to cover the needs of residents. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 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 standard(s) EVIDENCE: These standards were not assessed at this inspection. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 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 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 and 36 Staff have the competencies and training required to meet residents’ needs. They are supported by an effective staff team. In general there are robust recruitment and selection procedures although slight improvement would offer further safeguards. Residents benefit from well supported and supervised staff. EVIDENCE: There is a strong commitment towards staff training. For example, new staff complete a number of mandatory training courses prior to commencing duties at the home. At present there is only one member of the staff team who is qualified to NVQ II or above however, there has recently been a turnover of staff. There are seven support staff employed; four of whom have been appointed in 2005 (although one of these staff is a former employee who has recently returned). There are some staff who are currently undergoing NVQ training. The Registered Manager is responsible for managing a number of other services and is supported by a home leader. The duty rota does not contain the weekly shift covered by the manager which must be addressed. There are regular staff meetings. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 20 New staff have undergone the appropriate pre-employment checks. However, copies of identification must be retained. It was also ascertained that although two written references had been obtained prior to employment, in one instance references had been supplied by the worker’s peers rather than the manager of the establishment where they had previously worked. During interviews staff reported that they felt supported by management and were always able to seek advice and guidance. They demonstrated a good awareness of the needs of residents. There is regular structured supervision. Supervision records examined were comprehensive and covered a wide selection of topics. It was pleasing to see that any issues raised during this process were acted upon in a proactive manner by the home leader. The organisation has introduced a comprehensive annual appraisal system. However this is currently being reviewed as feedback from staff has indicated that this is too complex which is commendable. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 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 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, 39, 41 and 43 The manager is supported well by her senior staff in providing clear leadership through out the home with all staff demonstrating an awareness of their roles and responsibilities thereby protecting service users’ rights and interests. There is on-going improvement in the quality assurance system to ensure that users’ views are included in the development of the service. Record keeping requires improving in order to demonstrate the efficiency of the service. The overall external management of the service ensures effectiveness although slight improvement is required in order to enhance this further. EVIDENCE: The Registered Manager for 73 Beech Road also manages a number of other services. The manager has been working for the organisation for a considerable period and regularly updates her knowledge through attending training courses. Interviews demonstrated she has a clear understanding of legislation and best practice and receives advice in a professional and constructive manner. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 22 Good progress is being made in progressing the quality assurance system. The organisation has established questionnaires for feedback from stake holders in the community and will build feedback into the systematic review of the service. As already detailed in this report record keeping requires improvement as it does not always reflect the high standard of care provided. For example, daily reports do not represent goals in care plans particularly with regard to independent living tasks and social activities which are undertaken. Health care monitoring and records also require improvement. Correctional fluid must not be used on documents such as medication administration record (MAR) sheets. There is up to date public liability insurance cover as well as insurance of residents’ personal effects. The business plan has been individualized as previously requested. There are regular visits by the owner’s representative. However, not all copies of monthly visits were available (for example, April, May and June 2005). These reports had also not been forwarded to the Commission for Social Care Inspection as required, and neither had the last report in July 2005. Information which is supplied on monthly reports needs greater detail in order to fully comply with the Care Homes Regulations 2001, Regulation 26 and in order to be able to form an opinion of the standard of care provided. Information has already been supplied to organisation. Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 4 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 2 2 2 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beech Road (73) Score x 2 x 2 Standard No 37 38 39 40 41 42 43 Score 3 x 2 x 2 x 2 E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 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 5 Regulation 5(1)(b) Requirement Timescale for action 1/12/05 2. 7 15 3. 9 (13(4)(c) 4. 16 17(1)(a) Review the statement of terms and conditions/contract to ensure it meets standard 5.2 of the National Minimum Standards for Younger Adults.To ensure that the statement of terms and conditions of residency is signed by either the service user and/or representative. Where the service user is unable to sign and there is no immediate family, the use of an advocacy service must be sought. (Previous timescale of 31/3/04 is partially met). To establish a written care plan 1/12/05 for an identified service user who requires support to manage finances and assistance from staff in making withdrawals from a bank account. To review and expand risk 1/11/05 assessments for wheelchair users identifying risk associated with using posture belts and manufacturers specifications with regard to maintenance checks and servicing. To negotiate any restrictions 1/12/05 upon service users’ rights with advocates such as families and Version 1.40 Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Page 25 5. 19 12(1)(a) social workers and record outcomes in individual service user plans. For example, staff opening service users’ mail and inappropriate bedroom door locking mechanisms which cannot be operated by a key. (Previous timescale of 1/8/05 is partly met). To improve record keeping and 1/11/05 monitoring with regard to service users access to health care appointments and to ensure that these are fully up to date for example: annual attendance at well person clinics. To ensure that all care plans contain a formal procedure for the monitoring of service users’ health with regard to potential complications such as breast screening, testicular screening through observational checks. Any issues relating to capacity to consent regarding invasive screening must be discussed with the General Pracititioner and outcomes recorded in individual care plans. To improve the control and administration of medication by: 1) To provide training for care staff in administration of medications, there use/side effects, and the homes medication policy. (Previous timescale of 31/3/04 is partly met). 2) To ensure that two staff initials are obtained to confirm any changes made to computerized instructions on Medication Administration Record (MAR) sheets. (Previous timescale of 1/6/05 is not met). 6. 20 13(2) 1/11/05 Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 26 3) To ensure copies of reports from visits undertaken by the pharmacist are retained. (Previous timescale of 1/6/05 is not met). 4) To cease the use of correctional fluid on medication administration record (MAR) sheets. 5) To ensure that advice is sought from the General Practitioner rather than the medical practice receptionist with regard to ailments and the treatment thereof. 6) To establish a written household remedy policy for all individual service users which must be ratified by the General Practitioner (and include the actual name of the service user). 7. 21 12(3) To work towards ascertaining the 1/12/05 wishes/ feelings of service users and their representatives re the issue of ageing/terminal care.This must be documented in the service users plan. (Previous timescale of 31/3/04 is partly met). To review the practice of service 1/11/05 users funding the cost of their own meals whilst out in the community, which are in place of meals provided by the Home. This practice must be negotiated with funding authorities and service users’ advocates at forthcoming review meetings. If this practice is to continue, a formal procedure must be agreed which is contained in individual service users’ plans. Version 1.40 Page 27 8. 23 17(2) Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc (Previous timescale of 1/7/05 is partly met). To ensure a copy of the Department of Health guidance on the Protection of Vulnerable Adults Scheme (POVA) is retained on the premises. To progress plans to ensure that all new staff have received training in vulnerable adult abuse. 9. 24 23(2)(b) To ensure that all wardrobes are 1/10/05 fully secured to bedroom walls. (Previous timescale of 1/6/05 is not met). To ensure that 50 of the care 1/12/05 staff team are qualified to NVQ II or above by 2005. To carry out written risk 1/10/05 assessments with regard to staff who work in excess of 48 hours per week (Working Time Regulations 1998). (Previous timescale of 1/12/04 is not met). To ensure that the hours worked by the Registered Manager is included on the duty rota. Ensure all relevant checks are undertaken in relation to the recruitment of staff and enhanced CRB checks for existing staff (to retain evidence of POVA First checks on the premises). (Previous timescale of 31/1/04 is partly met). To ensure that references are obatined from suitable referees such as former managers rather than peers/colleagues. Implement a system of annual staff appraisals. (Previous timescale of 31/3/04 is partly met). 10. 11. 32 33 18(1)(c) 17(2) 12. 34 19(1)(b) 1/10/05 13. 36 18(2) 1/12/05 Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 28 14. 15. 37 39 18(1)(c) 24 16. 41 17(3) 17. 42 13(4)(c) To ensure that the Registered Manager is qualified to NVQ IV in care and management by 2005. To review and further develop quality assurance system to incorporate feedback from stakeholders and families. (Previous timescale of 1/8/05 is partly met). To improve general record keeping for example with regard to health care monitoring. To ensure that daily reports reflect goals and objectives contained within individual care plans, for example with regard to daily living skills and social activities. To provide evidence that minor works identified in the Electrical Installation Report have been carried out. (Previous timescale of 31/3/04 is not met). To ensure that copies of the monthly reports from visits undertaken by the Owners representative are available on the premises and a copy forwarded to the Commission for Social Care Inspection. To ensure that the reports contains information in sufficient detail as requried by the Care Homes Regulations. 31/12/05 1/12/05 1/11/05 1/12/05 18. 43 26 1/10/05 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 Good Practice Recommendations Beech Road (73) E55_s4809_73 Beech Road_v237242_220805_Stg4.doc Version 1.40 Page 29 Commission for Social Care Inspection Halesowen Office - Mucklow Office Park West Point, Ground Floor Mucklow Hill Halesowen, West Midlands 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. 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