Inspection on 27/01/06 for 73 Beech Road

This inspection was carried out on 27th January 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

73 Beech Road 15/12/08

73 Beech Road 16/08/06

73 Beech Road 22/08/05

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 73 Beech Road Wednesbury West Midlands WS10 9NR Lead Inspector Jayne Fisher Unannounced Inspection 27th January 2006 09:00 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 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 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 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. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 73 Beech Road Address Wednesbury West Midlands WS10 9NR 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) 0121 502 1418 NONE Pioneer Care Limited Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22 August 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 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 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between the hours of 9.00 a.m. and 1.00 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 home leader, and a member of support staff who were on duty. There was also a tour of the premises. Two of the three residents were at home during the varying stages of the inspection. Open dialogue was not possible with residents 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 from reports of visits undertaken by the owner’s representative and an action plan submitted by the home following the last inspection. Beech Road provides intensive support for people with learning disabilities and associated complex needs such as communication difficulties. The majority of standards were examined at the last inspection and this report should therefore be read in conjunction with the previous inspection report to give a comprehensive overview. 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: Care plans and risk assessments are comprehensive and provide staff with excellent guidelines in meeting residents’ complex needs. Staff ensure that residents’ healthcare needs are assessed and recognised so that any potential complications can be quickly dealt with. Residents looked content and well cared for. There was lots of positive interaction observed between staff and residents; with staff demonstrating a patient and sensitive approach. Daily routines are flexible and suit residents’ individual needs. The environment is exceptionally clean, comfortably furnished, and homely through out. Residents’ bedrooms contained lots of personal possessions and ‘homely’ touches with staff clearly making an effort to ensure décor and furnishings reflect residents’ personalities and tastes. Residents and staff are supported by a dedicated, competent and experienced management team. There is excellent support given to new staff with formal and informal supervision. Where possible, new staff receive the majority of their training before they commence their duties. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Residents’ contracts need further information so that they are made fully aware of their entitlements to services. Residents are offered opportunities to choose what they want to eat however slight improvements could be made in making the meals offered more varied. Record keeping needs to be more consistent with regard to recording what residents’ have chosen to eat on a daily basis. Some slight improvements are needed with regard to food hygiene and infection control practice. At the last inspection it was identified that the owner’s representative was not completing reports of monthly visits undertaken, as required by care homes legislation. This inspection identified that these visits are not being carried out on a monthly basis. This must receive appropriate action by the service provider. On the whole this inspection confirmed that staff are continuing to provide an excellent service. There are a couple of areas however which were not in keeping with the usual high standards. An untrained member of staff has been responsible for administration of medication which has resulted in a medication error whereby one resident did not receive their medication, (some action had already been taken by management). On arrival in the morning a member of staff was seen smoking in the communal kitchen which does not comply with company policy. The home leader gave assurances that these issues would be immediately dealt with. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 7 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. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 8 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 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 9 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): These standards were not assessed at this inspection. EVIDENCE: Progress was monitored towards an outstanding requirement in respect of service users’ terms and conditions of occupancy. These still require updating as previously required. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: It was pleasing to see that progress has been made towards the outstanding requirement in respect of ensuring a care plan has been expanded with regard to one service user who is receiving support from staff to manage their own finances. Good guidelines were included for staff to follow in supporting this resident. Risk assessments have been updated for wheelchair users but further details are required with regard to risks which have been identified by the Medicines and Healthcare Products Regulatory Agency in January and April 2005. (Information was supplied at the last visit). The quality of daily reporting systems have also been improved following the last inspection. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 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): 17 Residents are offered a healthy and well balanced diet. EVIDENCE: The home does not provide a set weekly menu. Instead service users are able to choose what they would like to eat on a daily basis from food stuffs they have purchased themselves on shopping trips which is an excellent initiative. The home leader stated that current practice is being reviewed and hopefully this will assist in providing a more varied menu as some meals are slightly repetitive. Examination of food records confirms that residents can have choices however these records need to be more consistently completed. In addition more details are required in some instances particularly where staff have simply recorded that residents have had ‘sandwiches’. Fridge, freezers and cupboards are well stocked with good quality food products. Slight attention needs to be given to stock control and rotation as a small quantity of vegetables were found to be six days past the sell by date on the packaging. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 12 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 and 20 Staff provide sensitive and flexible personal support to service users. The procedures for the control and administration of medication need improvement in order to ensure systems are safer for residents. EVIDENCE: There are comprehensive care plans in place with excellent details of how residents prefer to receive support with personal care. Daily diaries record residents’ bedtimes and bath times which demonstrate flexibility. Staff continue to ensure that the health care needs of residents are met. There has been improved recording of health care appointments and treatments; there are monthly as well as six monthly review sheets. Since the last inspection more comprehensive care plans have been introduced with regard to screening for potential complications from breast and testicular cancer including good guidelines for staff with regard to observation and monitoring. Two residents were due to attend well person clinics on the day of the inspection and the third has an appointment for the following week. There was only one new issue identified in respect of residents receiving hourly checks during the night time. As changes of incontinence pads are usually not necessary during the night, consideration needs to be given as to why these checks are necessary given there is no physical or medical justification. The 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 13 home leader acknowledged that this may be practice that is not necessary and will undertake a review. It was pleasing to see that the majority of outstanding requirements with regard to medication had been addressed. However, a serious concern was identified in respect of untrained staff administering medication. Upon examination of a staff formal supervision record (see further comment in standard 36), it was ascertained that the home leader had recently disciplined a member of staff for misconduct including this medication error. The member of staff in question is a new member of staff who has had no previous experience in social care, and who has received no formal certificated training in the safe handling of medication. A couple of gaps were also found in medication administration record (MAR) sheets although medication had been administered on this occasion. An Immediate Requirement was issued for this member of staff to cease administration of medication until appropriate training has been undertaken. Generally, apart from this issue, practice relating to medication is quite good with only a small number of items needing attention. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 14 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): These standards were not assessed at this inspection. EVIDENCE: Progress was monitored towards requirements identified at the last inspection. It was pleasing to see that the home leader has obtained a copy of the Protection of Vulnerable Adult (POVA) guidelines as requested. New staff still require training in vulnerable adult abuse procedures. A written protocol still needs to be devised with regard to meals paid for by residents on an occasional basis when out in the community. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 15 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 and 30 The standard of the environment within this home is good providing service users with an attractive and homely place to live. The home is very clean and generally there is good infection control practice although slight improvements would offer more safeguards for residents. EVIDENCE: A tour of the premises revealed that the home continues to maintain good standards with regard to the environment. All rooms were seen to be clean and tidy with good quality décor and furnishings. All bedrooms are decorated and furnished to a high standard and individualised with personal possessions, photographs and stereo equipment. It is pleasing to see that colour schemes, décor and furnishings reflect service users’ individual tastes. Staff have made very good efforts to ensure that the environment is comfortable and homely. There is no separate laundry area. The washing machine and tumble dryer are located in the kitchen. Discussions with staff and management confirms that good infection control practice is followed and is appropriate to residents’ current needs and requirements. Only slight improvements are necessary. For example the kitchen flooring is no longer impermeable being torn in places. There was a supply of liquid soap and paper towels in the kitchen although it is 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 16 suggested that a paper towel dispenser would be more beneficial than storing a pack of paper towels underneath the sink unit. There was a supply of disposable gloves in the kitchen; aprons are stored an adjacent cupboard (a supply should also be kept in the kitchen). It is also suggested that enquiries should also be made with regard to the provision of a small wash hand basin in the kitchen to improve infection control practice further. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 17 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): 35 Training is given a high priority however specialist induction training would help new staff in supporting residents who have complex needs. EVIDENCE: Progress was monitored towards outstanding requirements. Good progress is being made towards vocational training for staff. Statutory training was assessed at the last inspection and found to be up to date. It was pleasing to see that the registered manager is now included on duty rota as requested. Risk assessments have been undertaken for staff who work in excess of the Working time Regulations 1998. Improvements have also been made with regard to recruitment and selection procedures as evidenced through examination of a new member of staff’s personnel file. There is only one shortfall with regard to maintaining a copy of identification on the premises. There is an up to date central staff training and development programme. Staff were also seen to have up to date individual training and development profiles in their files. New staff require training in equality and disability awareness. Problems have been incurred with induction and foundation training programmes for new staff which are provided by an accredited learning disability awards framework (LDAF) provider. The home leader 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 18 thinks that these issues may now have been resolved and the new member of staff who commenced employment before Christmas should be due to go on appropriate training in the near future. An annual appraisal system still needs to be fully implemented. The home leader is to be commended on the quality and frequency of formal supervision given to new staff. Records were comprehensive and demonstrated a professional and supportive approach to performance management. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 19 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): 42 Management ensure that so far as is reasonably practicable, the health, safety and welfare of residents is maintained and protected. EVIDENCE: A number of maintenance and service records were sampled and found to be up to date. For example, there is weekly testing of the smoke alarm system, annual inspection of the fire maintenance equipment and weekly testing of the water temperatures. Portable electrical appliances had received annual testing. There was also an up to date gas safety certificate. Health and safety procedures are currently being reviewed which is a good initiative. A couple of new items were identified at this inspection. A electrical adaptor was seen on the kitchen floor which is needed to utilize the fridge/freezer and tumbler dryer. Given issues relating to electrical and fire safety more electrical sockets are required and in the interim a risk assessment must be completed. Improvements are needed with regard to food hygiene practice in respect of checking and recording cooked food, fridge and freezer temperatures. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 20 The owner’s representative is not completing monthly reports (the last report available was October 2005). In addition visits are not being conducted on a monthly basis as required by the Care Homes Regulations 2001, Regulation 26. As already mentioned in this report two incidents have occurred with regard to a medication error and staff misconduct. The Commission for Social Care Inspection had not been notified of either as in compliance with the Care Homes Regulations 2001, Regulation 37. This was discussed with the home leader. Any other items discussed during this inspection are contained within the Requirements section of this report. 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 1 X X X X X X 2 X 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 22 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 YA5 Regulation 5(1)(b) Requirement Timescale for action 01/04/06 2. YA9 (13(4)(c) 3. YA16 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 review and expand risk 01/04/06 assessments for wheelchair users identifying risk associated with using posture belts and manufacturers specifications with regard to maintenance checks and servicing. (Previous timescale of 1/11/05 is not met). To negotiate any restrictions 01/05/06 upon service users rights with advocates such as families and social workers and record outcomes in individual service user plans. For example, staff opening service users mail and DS0000004809.V280594.R01.S.doc Version 5.1 73 Beech Road Page 23 4. YA17 17(1a) 17(2) 16(2i) inappropriate bedroom door locking mechanisms which cannot be operated by a key. (Previous timescale of 1/8/05 is partly met). To ensure that service users 01/05/06 daily food choices are more consistently recorded, and are more detailed in content. To continue to pursue plans to review menu planning in order to encourage more variety in options available for residents. To review practice of hourly 01/04/06 night checks for all service users. Care plans must be updated accordingly with outcomes of individual reviews. If this level of monitoring is deemed necessary, individual risk assessments must be carried out to demonstrate why these levels of monitoring are required. To ensure that staff do not smoke on the premises including communal areas such as the kitchen. To improve the control and 01/04/06 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 only staff who have undertaken some form of certificated medication training are responsible for the administration of medication. IMMEDIATE REQUIREMENT – 27/1/06 5. YA19 12(1)(a) 6. YA20 13(2) 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 24 3) To review and expand medication policy using guidelines issued by the British Pharmaceutical Society, June 2003. 4) To retain copies of original prescriptions (or new prescriptions when medication is changed) and maintain in individual service user plans. 5) To ensure prescriptions are checked and signed prior to sending to the pharmacist for dispensing, in line with the medication policy and good practice guidelines. 6) To update the staff specimen signature and initial list. 7) To ensure more accurate completing of the medication administration record (MAR) sheets. 8) To ensure that tubes of creams/ointments are labelled with the date of opening. 7. YA21 12(3) To work towards ascertaining the 01/05/06 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 01/05/06 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 DS0000004809.V280594.R01.S.doc Version 5.1 Page 25 8. YA23 17(2) 73 Beech Road forthcoming review meetings. If this practice is to continue, a formal procedure must be agreed which is contained in individual service users plans. (Previous timescale of 1/7/05 is partly met). To progress plans to ensure that all new staff have received training in vulnerable adult abuse. (Previous timescale of 1/11/05 is not met). 9. YA24 23(2)(b) To ensure that there is more readable access to thermostatic controls on radiators which are currently inaccessible due to radiator covers. To make the following improvements to infection control practice: To install a paper towel dispenser in the kitchen area. To seek advice as to the feasibility of installing a small wash hand basin in the kitchen area. To repair worn and torn kitchen flooring. 11. YA32 18(1)(c) To ensure that 50 of the care 01/05/06 staff team are qualified to NVQ II or above by 2005. (Previous timescale of 1/12/05 is not met). To ensure that all new staff are 01/05/06 registered on a Learning Disability Awards Framework (LDAF) induction (to be completed within the first six weeks of employment) and foundation training (to be completed within the first six months of employment) course which is provided by an DS0000004809.V280594.R01.S.doc Version 5.1 Page 26 01/06/06 10. YA30 13(3) 01/05/06 12 YA35 18(1)(c) 73 Beech Road accredited LDAF trainer. 13. YA36 18(2) 14. YA37 18(1)(c) 15. YA39 24 16. YA41 17 To ensure that all staff receive equal opportunities including disability equality training. Implement a system of annual staff appraisals. (Previous timescale of 31/3/04 is partly met). To ensure that the Registered Manager is qualified to NVQ IV in care and management by 2005. (Not assessed at this visit). 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 obtain and hold information and documents in respect of persons carrying on, managing or working at a care home as listed in Schedule 2 and 4 of the Care Home Regulations 2001. 01/05/06 01/04/06 01/05/06 01/04/06 17. YA42 13(4)(c) To ensure that the Commission for Social Care Inspection is kept informed of all events affecting the well being of service users and/or staff. To provide evidence that minor 01/04/06 works identified in the Electrical Installation Report have been carried out. (Previous timescale of 31/3/04 is not met). To install additional electrical sockets in the kitchen area. In the interim to carry out a written risk assessment with regard to the use of electrical adaptors in documented liaison with the fire service. To include the names of staff participating in the regular fire evacuation drills in order to 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 27 ensure that all staff participate in a minimum of a bi-annual drill. 18. YA42 13(4)(c) To ensure more consistent daily fridge, freezer and cooked food temperatures are checked with records kept in compliance with Food Hygiene Regulations 1990. 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 required by the Care Homes Regulations. To ensure that visits are undertaken on a monthly basis by the Owner’s representative in order to form an opinion as to the conduct of the home. 01/04/06 19. YA43 26 01/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 73 Beech Road DS0000004809.V280594.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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