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Inspection on 02/02/06 for Albert Road (8b) (Hightrees)

Also see our care home review for Albert Road (8b) (Hightrees) for more information

This inspection was carried out on 2nd February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The inspectors found the men living at Hightrees were very relaxed and comfortable in the home. The manager reported that one man had spontaneously told her that morning he was happy living at Hightrees, which he later said to inspectors as well. The men appeared to be very confident within the home, and helped themselves to drinks in the kitchen, and made or assisted with the preparation of their breakfast and lunch. The staff team are stable, and staff and the men have got to know and trust each other over a period of time. During the visit there was ongoing friendly chat and support. People the men know cover all vacant shifts. A new gentleman has moved into the home. He has had chance to visit over a long period and to get to know the other men accommodated. This appears to have made the move from one house to another smooth. The men have chance to undertake a lot of activities. This includes at the weekend, and in the evening. The activities include things of specific interest to one person, as well as activities such as bowling that are undertaken as a group. The men have all been supported with holidays that they requested. These were reported to have been really successful and to the enjoyment of each of the men. The staff buy fresh foods of a good quality. The menu has a range of different foods on it from different cultures. Hightrees as a building is very homely. The shared areas are all comfortable and clean and tidy. The men all have a single room, and these contained the things that were important to them. The staff and manager help the men manage their money. It was clear that the money is checked regularly and receipts are obtained for all purchases. The inspector checked one person was getting their benefit paid to them. The care and support people need is mainly well planned for. Staff have written the documents, but have included information about how the men prefer their needs to be met, so these were very individual. There were no house rules about getting up or going to bed. It was nice to see people being supported with getting up when they were ready.

What has improved since the last inspection?

This home has continued to develop and improve since the last inspection. At the last inspection twelve requirements were made. Seven of these had been fully met, and one partly met.

What the care home could do better:

The manager and staff need to look at some areas of healthcare and improve the way this is planned for. This is to ensure the men get the support they need and can stay healthy. The premises need some work to ensure it is warm enough, and that the heating is reliable, that bathrooms are welcoming and free of bad smells, and that carpets are clean. The records to show staff have been checked fully before starting work must be available in the home. These were not available for all the staff.

CARE HOME ADULTS 18-65 Albert Road (8b) (Hightrees) Harborne Birmingham West Midlands B17 OAN Lead Inspector Alison Ridge Unannounced Inspection 2nd February 2006 09:30 Albert Road (8b) (Hightrees) DS0000016966.V281508.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 Albert Road (8b) (Hightrees) DS0000016966.V281508.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. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Albert Road (8b) (Hightrees) Address Harborne Birmingham West Midlands B17 OAN 0121 428 3410 0121 428 3423 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) Accord Housing Association Limited Ms Ruth Gavin Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 5th July 2005 Brief Description of the Service: 8B Albert Road, Hightrees, is a purpose built care home, which accommodates five men, who require care and support as they have a learning disability and some behaviour that challenge the service. The home is situated within a residential area of Harborne, and is close to local amenities, and transport links. The home has three ground floor bedrooms, a communal lounge, dining room, kitchen, and shower room. On the first floor are a further two bedrooms, a staff sleep in room/office, and a bathroom. The home offers off road parking for approximately four cars. The first impression of the home is very positive, with many planters and floral baskets maintained by service users. This is a home that has steadily improved in the past year. The standards assessed at this inspection were all met or partly met. The home has a stable staff team who understand and can meet the needs of the men accommodated. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The allocated regulation inspector undertook this visit with Alan Dennett (Business Relationship Manager) who was shadowing the inspector as part of his induction process. The visit was unannounced and undertaken over the morning and early afternoon of one day. During the visit the inspectors were pleased to meet all five of the men living at Hightrees, three of the staff and the home manager. Information was collected by talking with the men, staff and manager, looking at the premises, and reading records about care, health and safety, staffing and the general running of the home. This is a home that the inspectors think does a good job at helping the people living there to live an active and varied life, and which generally supports them meet their healthcare needs. This home was last visited by CSCI in July 2005. It is suggested that you read this report alongside the report of that visit to get a fuller picture of life in this home. The inspectors extend their thanks to everyone who helped with the inspection. What the service does well: The inspectors found the men living at Hightrees were very relaxed and comfortable in the home. The manager reported that one man had spontaneously told her that morning he was happy living at Hightrees, which he later said to inspectors as well. The men appeared to be very confident within the home, and helped themselves to drinks in the kitchen, and made or assisted with the preparation of their breakfast and lunch. The staff team are stable, and staff and the men have got to know and trust each other over a period of time. During the visit there was ongoing friendly chat and support. People the men know cover all vacant shifts. A new gentleman has moved into the home. He has had chance to visit over a long period and to get to know the other men accommodated. This appears to have made the move from one house to another smooth. The men have chance to undertake a lot of activities. This includes at the weekend, and in the evening. The activities include things of specific interest to Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 6 one person, as well as activities such as bowling that are undertaken as a group. The men have all been supported with holidays that they requested. These were reported to have been really successful and to the enjoyment of each of the men. The staff buy fresh foods of a good quality. The menu has a range of different foods on it from different cultures. Hightrees as a building is very homely. The shared areas are all comfortable and clean and tidy. The men all have a single room, and these contained the things that were important to them. The staff and manager help the men manage their money. It was clear that the money is checked regularly and receipts are obtained for all purchases. The inspector checked one person was getting their benefit paid to them. The care and support people need is mainly well planned for. Staff have written the documents, but have included information about how the men prefer their needs to be met, so these were very individual. There were no house rules about getting up or going to bed. It was nice to see people being supported with getting up when they were ready. What has improved since the last inspection? What they could do better: The manager and staff need to look at some areas of healthcare and improve the way this is planned for. This is to ensure the men get the support they need and can stay healthy. The premises need some work to ensure it is warm enough, and that the heating is reliable, that bathrooms are welcoming and free of bad smells, and that carpets are clean. The records to show staff have been checked fully before starting work must be available in the home. These were not available for all the staff. Albert Road (8b) (Hightrees) DS0000016966.V281508.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. Albert Road (8b) (Hightrees) DS0000016966.V281508.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 Albert Road (8b) (Hightrees) DS0000016966.V281508.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): 3, 5 Potential new service users are assessed prior to admission, and have chance to visit the home and “test-drive it”. Service users are issued with a contract which details the terms and conditions of their stay. EVIDENCE: The home has recently admitted one new service user. The work undertaken towards their resettlement was assessed in July 2005 and found to fully meet the required standards. When possible the contract will need to be explained to the service user, and signed by him or his representative. The cost of the placement was not stated on the contract. It was pleasing to see this work had continued, and to meet the service user during the inspection. Albert Road (8b) (Hightrees) DS0000016966.V281508.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): 6, 7, 8, 9, 10 Service users plans detail their needs and how they wish tem to be met. Service users are involved in the day-to-day running of the home, and are consulted about their wishes in one-to-one meetings with their key worker. Most information is securely stored. Personal information must not be displayed on notice boards. EVIDENCE: The plan of one service user was assessed in full, and parts of another two plans assessed in part. It was positive that staff who have a good understanding of and relationship with service users had developed plans of support and care. The plans were very personalised, and showed the preferences of each individual. The service user and their key-worker meet on a monthly basis to talk about the person’s wishes and plans. Some interesting ideas had come out of these meetings. It is recommended that staff review previous goals set at the commencement of each meeting to ensure they have been met, or progress made towards them. One service users risk assessments were sampled. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 11 The manager reported these would go on to be developed as staff gets a better understanding of the service user. The inspector considered the work undertaken to be positive, and detailed for the length of time the person had spent in the service. The interactions between staff and service users were entirely positive, and most confidential records about service users were stored securely. Some personal information was on display on a communal notice board and it was required these be removed. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 17 Service users have plentiful opportunities to undertake activities they choose and enjoy at all times of the day and week. Service users are supported to stay in touch with people who are important to them. Service users are provided with food of goof quality, including fresh products. A review of the portion size and nutrition of some meals has been requested. EVIDENCE: A small sample of the activities planned and undertaken in the week of inspection was undertaken. The activities planned included both group activities, and specific hobbies and interests of individuals. It was positive that the activities offered included exercise, leisure and personal development. The service users were all offered an activity of their preference during the visit, and four men undertook community activities. (Opportunity to go out was available for all the men, but one person chose to remain at home.) Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 13 The inspector found the culture of the home to very much be about supporting the men to undertake activities they enjoy. It was pleasing to see photos on display of activities and holidays previously undertaken, and to see that the gardening project is continuing. It was pleasing to hear from staff and to read in care notes that contact with family has been facilitated and supported. The running of the home was observed to be very respectful of the service users rights, and staff practice encouraged and facilitated people to take responsibility for them selves. The food available in the home was varied and nutritious. The stock included fresh fruit and vegetables. The menu largely comprised home cooked meals, with few processed products utilised. The service users were observed to choose their own breakfast, and where possible participate in the preparation. The inspector raised concern at the amount of carbohydrate and saturated fat offered in the lunch time meal, and the absence of any fruit or vegetables. It has been required this be reviewed. The inspector raised concern at the recent weight gain experienced by one service user, and required a referral to the dietetic department be made. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 Service users are supported to undertake personal care to a high standard in the way and at a time that they prefer. This service user group have a range of complex and additional needs. Generally the inspection identified these were being well met. EVIDENCE: The inspectors were pleased to meet with all five of the service users. All the men were supported to undertake personal care in the way and at the time they preferred. In the one service users plan sampled very detailed plans of care regarding meeting personal care needs were available. The record of health care appointments showed that a range of appointments had been offered to the men. It was positive that the new service user had been supported to access healthcare and register with the appropriate professionals. The only minor shortfall was that in one file it was not evident dental care had been offered. It was positive that service users had been supported to develop a health action plan, and that healthy lifestyle goals had been planned in this. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 15 The work undertaken with one service user regarding healthy eating and weight management was tracked. While there is a plan in place it was identified that this required further development. It was of concern that recently the plan has not been effective resulting in weight gain. An immediate requirement was made that this person be referred to the Dietetic department. The possible changing needs of one service user were discussed. Staff had recently noted a change in toileting habits. It was of concern that this had not been brought to the attention of the GP or consultant to ensure any organic cause treated, and that possible psychological changes could be monitored. It is required this be undertaken. The assessment of one service user identified previous needs in the area of mental health. This had yet to be included in the plan, but the manager was aware of the need to develop this, and reported being in the process of collecting information. Medication management was not assessed at this inspection. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Hightrees has an open culture. Service users and staff feel able to raise ideas and suggestions. The manager was aware of the action to take in the event of abuse being alleged or reported. EVIDENCE: The manager had developed a flow chart making clear the points of contact in the event of abuse being reported or suspected. A copy of the current local agency guidelines were also available. It was positive that twelve of the fifteen staff files sampled showed that staff had received recent training in Adult Protection. Three staff are booked in for this course when next available. It was of concern that staff had raised concern about service users welfare in a staff meeting three days prior to the inspection. At the time of inspection no action to address or further explore these concerns had been undertaken. It was made an immediate requirement this be undertaken. The home has not received any complaints. The atmosphere in the home was very open, and opportunities are made available for service users to raise concerns Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 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 the following standard(s): 24, 25, 26, 27, 28, 30 Hightrees is domestic and homely, and meets the needs of people living in the home well. Some work is required on bathrooms, flooring, heating and to complete the new kitchen. EVIDENCE: The premises of Hightrees have been subject to considerable development, and now present as attractive and homely. The service users all appeared very comfortable in the home, and moved around freely. It was pleasing to see the service users had free access to the kitchen, and were aware of where items for making drinks and breakfast were stored. The inspectors thank the service users who kindly showed them their bedrooms. These had been personalised to the preference of the service user. The home has recently been fitted with a new kitchen. This was attractive and functional. Gaps were noted between the new paintwork and tiling which needs to be finished with a non permeable product to meet the food hygiene regulations. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 18 The hall carpet is an area of heavy wear. This has been previously identified as requiring attention and must be cleaned or replaced. The ground floor shower room is not an environment conducive to undertaking personal care. It is an outstanding requirement that this be refurbished and decorated. The gradient of the floor, and drainage of water was of concern, and the room remained wet at the time of inspection, despite it being some time after the last person had showered. The entrance to the first floor bathroom requires urgent replacement and this was left as an immediate requirement at the time of inspection. The ground floor wc continues to have an offensive odour. It was evident work to manage this had been tried but remain ineffective. This must be further explored. Hightrees has had longstanding problems with the heating. Reports on recent regulation 26 visits, minutes of staff and service users meetings, and discussion with staff and service users and at the time of inspection identified this is still not resolved. The home is required to utilise secondary heating to supplement the central heating. In the long term this is unsatisfactory. It was evident from work tickets that this has been repeatedly explored. It is urgently required that a resolution to this problem be obtained to ensure a sustainable and constant supply of heat. . Service users and staff work hard to ensure the home is kept clean to a high standard. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 36 Service users are supported by staff that they know, and who are experienced at working with them. New staff are inducted and welcomed into the team. All staff receive support and supervision. Recruitment records for all staff must be available to show that robust recruitment checks have been made. EVIDENCE: The rota identified that staff who the service users know had covered all shifts. The team is well established, and the majority of the team have worked together for a pro-longed period. The atmosphere in the home and interactions between service users and staff were friendly, supportive and positive. It was pleasing to hear from one new staff member that she had been welcomed into the team, and supported by both colleagues and the management team. Staff files showed that new staff receive an induction in to the home. Recruitment records were not available for recent starters. The provider must ensure that systems are in place by which these can be received and checked by the home manager prior to the person starting work. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 20 The supervisions undertaken with two staff were sampled. These were to a high standard covering welfare, practice and development. They had been undertaken at least bi-monthly. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 41, 42 This is a well run home which has the needs and wishes of the service users at the heart of day-to-day operation. Service users, staff and visitors are protected by health and safety checks and good administration and record keeping. EVIDENCE: The inspection identified this continues to be a well run home which has the needs and wishes of the service users at the heart of day-to-day operation. The manager has completed the required level of training, and has experience of working with this service user group. The receipt of one persons benefit was tracked. It was evident this is generally checked, to ensure receipt, but at the time of inspection this had not been undertaken since October 2005. The record of regulation 26 visits to the home does not show these have been undertaken with the required frequency. A gap in visits between July and December 2005 was evident in both the home and CSCI records. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 22 There was a current certificate of registration and employers liability insurance available in the home. The money of three service users was audited for January 2006. The records tallied with receipts, and money available. Records of fire safety testing showed this had been undertaken as required. Hot water delivery temperatures had been checked by staff and were within safe ranges. Food hygiene practice was good, and food all safely stored and wrapped. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 2 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 X X 3 X X X 2 3 X Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 17(1a) Sch3 Requirement When possible the service user or their representative must sign the contract. The contract must include fees and what these cover. Personal and confidential information about people must be stored securely. The manager must review the content of meals to ensure a balanced range of foods is offered. The manager must offer one service user access to the dietetic service. Not fully met from the last inspection. A care plan to underpin a low fat diet and healthy eating regime must be developed. All service users must be offered access to dental care and a record of this maintained in the home. The manager must seek medical and psychological advice regarding one service users changing needs. The manager must ensure staff concerns regards service users DS0000016966.V281508.R01.S.doc Timescale for action 01/04/06 2. 3. YA10 YA17 12(4)(a) 16(2)(i) 24/02/06 24/02/06 4. 5. YA17YA19 YA19 12(1)(a) 13(1)(b) 12(1)(a) 13/02/06 01/04/06 6. YA19 12(1)(a) 13(1)(b) 12(1)(a) 13(1)(b) 13(6) 01/04/06 7. YA19 01/03/06 8. YA23 13/02/06 Albert Road (8b) (Hightrees) Version 5.1 Page 25 9. YA24 10. YA24 11. YA26 12. 13. YA27 YA30 14. 15. 16. 17. YA30 YA34 YA41 YA41 welfare are robustly explored and the required action taken. 23(2)(p) A sustainable and reliable source of heating must be available at the home at all times. 23(2)(b)(d) Unmet since the last inspection Carpet in the hallway must be cleansed to a satisfactory standard or replaced. 23(2)(b)(d) Unmet since the last inspection Lino floor in one service users bedroom must be replaced with carpet. 23(2)(d) Unmet since the last inspection. The ground floor shower room requires refurbishment. 16(2)(k) Unmet since the last inspection. The odour in the ground floor toilet must be effectively managed/removed. 23(5) The kitchen walls must be finished with a non-permeable product. 19 Recruitment files must be Sch 3&4 available for all staff working in the home. 13(6) Staff must evidence receipt of service users money has been checked. 26 Regulation 26 visits must be undertaken monthly, and a record of such maintained in the home. 01/04/06 01/05/06 01/05/06 01/05/06 01/04/06 01/04/06 01/04/06 01/03/06 01/04/06 Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 26 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. 2. Refer to Standard YA6 YA8 Good Practice Recommendations It is recommended that Person Centred Plans as identified in the Government white paper Valuing People be developed with service users. It is recommended that the goals set at service users meetings be kept under review to ensure they are met. Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Albert Road (8b) (Hightrees) DS0000016966.V281508.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!