Inspection on 17/08/05 for Alvechurch Road, 76

This inspection was carried out on 17th August 2005.

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

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

Other inspections for this house

Alvechurch Road, 76 28/08/09

Alvechurch Road, 76 03/08/07

Alvechurch Road, 76 19/07/06

Alvechurch Road, 76 02/02/06

Alvechurch Road, 76 14/12/04

Alvechurch Road, 76 03/08/04

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Polesworth Group Pooley Heights

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Alvechurch Road, 76 76 Alvechurch Road West Heath Birmingham B31 3QW Lead Inspector Gerard Hammond Unannounced 17 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Alvechurch Road, 76 Address 76 Alvechurch Road West Heath Birmingham B31 3QW 0121 258 0887 0121 258 0887 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) FCH Housing & Care Vacant Care Home 6 Category(ies) of Younger Adults, Learning Disability [6] registration, with number of places Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 14 December 2004 Brief Description of the Service: 76 Alvechurch Road is registered to provide accommodation, care and support for up to six adults with learning disabilities. The house is a spacious domesticscale property located in the West Heath area of Birmingham, close to shops and local amenities, and well served by public transport. There is off-road parking at the front of the house. Accommodation is provided in single bedrooms, two on the ground floor and four on the first floor, which can be accessed either by the main staircase or by a passenger lift. Downstairs there is a good sized lounge / dining room, kitchen and separate laundry. There is also an assisted shower room, with w.c. and wash hand basin, and a further separate w.c. Upstairs are two bathrooms (one assisted), both with w.c. and wash hand basins. The office is also situated on the first floor. To the rear of the property is a secure private garden, with a patio and seating area, and lawn edged with planted border. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the course of this inspection, the Inspector was assisted by Stephen Ellis, a member of “Experts by Experience” (an organisation of people with learning difficulties, whose own experiences of life give them a unique perspective and expertise) or XbyX for short. Throughout this report, Stephen is identified as “the XbyX”. During the inspection visit Stephen was supported by a member of staff from People First (Sandwell). Thanks are due to the residents and staff at Alvechurch Road for their co-operation in this work and for their welcome. Direct observation and sampling of records (including personal files and safety records) were undertaken for the purposes of compiling this report. The Inspector met with all of the residents and interviewed the Acting Manager (covering the newly-appointed Manager’s post, due to sick leave), Service Manager and two members of staff. A tour of the building was also completed. What the service does well: What has improved since the last inspection? The Home is in a transitional phase since the last inspection. A new manager has been appointed but has been away from the home on sick leave for a significant period. This situation was known about and planned for within the Organisation, and an existing Manager has been covering the post in the interim. Clear efforts are being made within the Organisation towards addressing outstanding issues and to meeting requirements, and this situation should improve further when the newly appointed Manager is able to resume her position. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 6 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. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.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 Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.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) 1, 2, 5 Information required by prospective users of this service should be made available. Residents’ needs and aspirations are assessed, but the admissions policy should make it explicit that this is required prior to placement. Residents should be provided with copies of their individual contracts, which should be current and compliant with Standard 5. EVIDENCE: There have been no admissions to the Home since the last inspection. Previous requirements to produce an up to date Statement of Purpose and Service User Guide remain outstanding. It should be acknowledged that circumstances have dictated that this task assumed a lower order of priority in recent months, and that some work has gone on to producing a draft, but both these documents should now be completed and made available, as required. Sampling of residents’ files provided evidence of appropriate statements of individuals’ strengths and support needs, and conversations with staff demonstrated a good level of understanding and awareness of these also. The admissions policy requires amending to include an explicit statement that no one is admitted without a full assessment. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 9 Each resident should have a copy of his or her current contract, in accordance with the requirements of National Minimum Standard 5. It is recommended that contract documents offer the option of countersignature by a relative or other independent person, for those residents unable to sign for themselves. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.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, 9 Residents’ needs are reflected in their care plans, but these should be developed further to include their goals and aspirations. Residents make choices and decisions, with support from staff if required. Residents’ independence through responsible risk taking is encouraged, but risk assessments are in need of some development. EVIDENCE: Residents’ care plans are in need of development. In order to prepare for this, it is recommended that personal files are given a “tidy up” so as to facilitate the management of essential information. Old material or material that has been superseded should be archived or disposed of as appropriate. Ideally, the working file should only contain information that is current. An accurate, up to date index could also improve the accessibility of important information, and it is helpful if care plans and risk assessments in particular are clearly and consistently numbered. Useful formats are available within the Organisation, and these should be used appropriately. Individuals’ care plans should incorporate goals with outcomes that can be measured. These should be set in consultation with the person concerned, as Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 11 much as is possible. A whole care plan review should take place at least every six months, when goals set and outcomes achieved should be evaluated in detail. A written record should be kept of the review, indicating who takes part, and how decisions are made. It is recommended that person-centred approaches, in keeping with the aspirations of the Government White Paper “Valuing People” be considered, while undertaking the review and development of plans. The XbyX asked residents if they knew about their care plans. He reported,” none of them knew what a care plan or person-centred plan was”. He further observed that he did not consider that people had ownership of their “tenant profiles”, and that more work needed to be done on these. He said, “I hope that the profiles will be easy to read and understand”. Residents in this house clearly exercise their rights to make choices and decisions, though the level at which this takes place varies considerably from person to person, in accordance with their individual abilities. Some are able to make positive choices about where they go, and in some instances able to travel independently. This was witnessed directly. Others need encouragement and prompting to make choices, and staff were observed engaging with residents effectively to support this, for example what to wear and what activity to undertake. Residents told the XbyX that they go shopping with members of staff. One said, “I can choose the shopping when I go”, and another one told him, “I have been shopping this morning and helped with the bags. I chose sausage for tea”. Staff recognise that responsible risk taking is an important component in supporting people to be as independent as they can. In some instances it was seen that risk assessments were clearly linked to statements of need and plans of care, and this practice needs to be extended. Risk assessments should be directly cross-referenced to the care plan(s) to which they relate, and vice versa. Some risk assessments also require review so as to ensure that potential hazards are identified correctly, a clear judgement made about the likelihood of occurrence, and indicating control measures designed to eradicate or minimise the risk. Control measures should then be incorporated into individual plans of care appropriately. It may be helpful if the format used for processing risk assessment is standardized, as moving from one to another was found to be confusing. It is also important that documents are signed and dated, so that it is absolutely clear when risks were assessed, and when they might require reviewing. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.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) 12, 13, 15, 16, 17 Residents are able to pursue valued activities and to be a part of their local community. They are supported to maintain friendships and family relationships, both at home and away from the house. Residents’ rights are respected, and they are encouraged responsibility so as to enhance their levels of independence. They have access to a varied and balanced diet. EVIDENCE: Some residents access regular, formally structured day care opportunities at local centres or colleges (during term time), while others exercise a positive choice to be at home and access community facilities with staff support on a more informal basis. One man has an Autistic Spectrum Disorder and does not cope well with unfamiliar environments or strangers, but is content to follow routine activities with the support of people he knows well. Residents who attend centres speak very positively about their activities, which are clearly Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 13 to accept enjoyed and valued. In addition, people in the house use local shops, pubs and clubs in the neighbourhood. One woman enjoys reading in particular, and has a collection of films that she likes to watch on video at home. Staff support residents to keep in touch with friends and family, both at home and away from the house. Particular efforts are currently being made to locate relatives of one woman, enlisting the help of her Social Worker. One of the men has a longstanding friendship with a volunteer worker and goes out to see him regularly at weekends. Residents’ rights are recognised and respected by members of the care team, who encourage them to be as independent as they are able. There is a rota on the kitchen wall for loading the dishwasher, and this was organised by one of the residents, who also ensures that duties are not forgotten about. Another resident particularly likes to have the responsibility of looking after her own room, and staff support her with her permission. People told the XbyX that they helped to write the shopping list for the house every week. Records of meals provided gave evidence of residents having access to a varied and balanced diet, and this was borne out by an examination of food stocks, which were plentiful and included fresh produce. The XbyX liked the fact that people do not have to stick to a set menu, and were actively involved in choosing and buying the food. He said that only one person had any “issues” about the food and that was to say, “I don’t think that we should have stews and casseroles in the summer, they are winter food. We should have more salad or cold things”. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.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) 18, 19, 20 Support is given in accordance with residents’ needs and preferences. Residents’ healthcare needs are met appropriately, and they are protected by the Home’s medication procedures and practice. EVIDENCE: It is quite evident that residents and staff in this house enjoy a good rapport, and are comfortable in each other’s company. Interactions were seen to be warm and friendly and appropriately respectful. Staff spoke very positively about the regard they have for the people in their care, and it is clear that they have a genuine interest in their well-being. When residents returned home in the afternoon, staff on duty spontaneously asked them about their day and how they had been, spending time with them and involving then in preparations for the evening meal. Residents requiring support with aspects of their personal care were approached sensitively and with consideration. The XbyX noted that “staff seemed to get on really well with the residents, they included them in their conversations, they didn’t just talk amongst themselves”. Sample checking of personal records showed that a range of professionals are involved in supporting residents’ healthcare needs, including GP’s, Consultant Psychiatrist, Community Nurses, Psychologist, Chiropodist, Speech and Language Therapist, Optician and others. It was a recommendation of the last Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 15 inspection report that Health Action Plans should be developed for each resident. Information relating to this was seen on the day of the inspection, but this has yet to be put into practice. It should be acknowledged that the situation regarding the Manager’s absence has not helped in this regard. An examination of the Medication Administration Record showed no gaps, and a good system is in place for double-checking medicines as they are given. Protocols with regard to the administration of PRN (“as required”) medication are also in place. Practice with regard to handling and administration of medication was seen to be satisfactory. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.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, 23 Residents believe that their opinions and concerns are taken seriously, and action taken accordingly. General practice within the Home affords the people living there with protection from abuse, neglect and self-harm. EVIDENCE: There is a complaints policy and procedure in place that has previously been assessed as meeting this standard. It has to be asked how relevant a formal written procedure can be for people with learning disabilities, and this clearly varies according to the personal capabilities of each individual. It should also be acknowledged that this is well recognised within the Organisation, and measures are being taken to try and address this. A user-friendly complaints card is already available. Residents showed the XbyX their cards and explained how these can be used. The card has the person’s picture on it and is supplied with a stamped addressed envelope. In the event of any concern or complaint, the card is posted to the Organisation, and someone from outside the Home is sent to investigate. This is thought to be a good system: residents were involved in devising it, and it means that people do not have to write anything down. An audiotape is also said to be in production. In addition to the above arrangements, there is a house meeting every month, when any issues of concern can also be raised. The XbyX spoke with residents about this and observed, “I feel confident that the residents would be able to air their views without feeling nervous” The Home’s Adult Protection Policy was not seen on this occasion, but was assessed as appropriate at the last inspection. A recent allegation concerning a member of agency staff working at the Home was dealt with in accordance with local multi-agency guidelines, and appropriate action taken. The XbyX Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 17 commented that he felt residents are safe and well looked after, and noted that he was asked for identification by staff, before being admitted to the house. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.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) 24, 30 Residents enjoy living in a house that is generally homely, comfortable and safe, though some areas are in need of attention. The home is kept clean and tidy, with a good standard of hygiene maintained. EVIDENCE: A tour of the premises was undertaken on the day of the inspection visit. Efforts are made to maintain a good homely feel to the house. The lounge / dining room is comfortable, well used and very “lived in”. Residents’ own rooms are individual, with personal possessions and effects very much in evidence. The kitchen however, is certainly showing signs of its age, and in need of substantial refurbishment. Cabinets and worktop edges, including the seal around the main sink, are deteriorating and need replacing. Previous inspection reports have drawn attention to specific problems in the downstairs shower room. Although some attempts have been made to address these, the problems still remain. This is the most heavily used washing facility in the house, so these issues should now receive some priority. A full assessment should be conducted so that the root of problems identified can be properly established, and appropriate remedial action taken. Superficial examination suggests that lack of sufficient ventilation and condensation are Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 19 significant factors. The extractor fan appears to be in need of cleaning and may not be functioning as efficiently as it should. It was also noted that the grille on the floor of the shower area is very heavy and not easily removed for cleaning. A level entry floor to the shower area might provide the best solution to this particular problem. The garden area is generally very pleasant and enjoyed by people living in the house. However, the XbyX noted that the ashtray left on the patio table was full to overflowing, and recommended to the members of staff using it, that it should be emptied. The wooden handrail by the back door is deteriorating significantly, and should be replaced so as to avoid splinter injuries. The house is kept appropriately clean and tidy in general, and a good standard of hygiene is generally maintained throughout. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 20 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) 34 (This standard was not fully assessed on this occasion). EVIDENCE: In the Manager’s absence, it was decided that issues relating to staff would be assessed more fully at the next inspection. It was noted that not all of staff files included a recent photograph of staff members, and attention is drawn to the requirements of Regulations 17 and 19, and Schedules 2 and 4 (The Care Homes Regulations 2001) with regard to necessary documentation in this regard. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.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) 39, 42 Residents are happy that what they say has a positive effect on what goes on in their home. General practice in the Home promotes the health, safety and welfare of the residents. EVIDENCE: During the course of the inspection visit, the Inspector met with the Organisation’s Service Manager, and Acting Home Manager. Both demonstrated their awareness of issues requiring attention, and a positive attitude towards working to develop the service for the benefit of the people living in the house. The Organisation has made genuine efforts to develop quality assurance measures that can involve people who use their services, in a way that is meaningful to them as individuals. Questionnaires have been completed, but these should indicate clearly where assistance has been given, and by whom. Ideally, if support is needed to engage in such an exercise, then this should be given by an independent person. It should be acknowledged that this is recognised, and that the development of appropriate quality Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 22 assurance measures remains a work in progress, and one that the Organisation is keen to promote, and to get right. Residents take part in house meetings every month. Individual people discussed this in detail with the XbyX. All agreed that they were able to talk about anything that they were unhappy with. When asked if anything was done about concerns that they raised, one said, “the Staff do listen and change things”, while another commented, “We have our say, we get things changed”. (See section on Concerns, Complaints and Protection also.) Safety records were also checked: The Home’s fire risk assessment was updated in April 2005. The fire alarm, fire fighting equipment and emergency lighting system have all been serviced, and regularly checked as required. Fire drills are carried out every month. The COSHH cupboard was seen and securely locked. It was noted that the COSHH file is currently under review, and that new data sheets were being obtained in order to bring records fully up to date. Opened packages of food stored in the fridge are correctly labelled with the date of opening, so as to promote effective stock rotation and safe and healthy eating. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.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 2 3 x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Alvechurch Road, 76 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.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. 2. Standard 1 2 Regulation 4 (1a) 17 (2) & Sch. 1 14 (1) Requirement The Statement of Purpose and Service User Guide should be completed and made available The Admissions Policy should be developed to include an explicit statement to the effect that a full assessment of individual needs should be completed prior to admission. Provide each resident with a copy of the current contract, which should contain all the information indicated in Standard 5.2 Develop individual care plans to incorporate goals, as identified in the main body of this report. Goals should be evaluated at reviews, which should take place at least every six months. Written records should be kept, indicating who takes part and how decisions are made. Risk assessments should be developed as indicated in the main body of this report, and directly cross-referenced to the care plan(s) to which they relate. Assess fully the problems in the downstairs shower room and take action to address issues Timescale for action 31 October 2005 31 October 2005 3. 5 5 (b-c) 17 (2) Sch.4(8) 15 (1-2) 31 October 2005 4. 6 30 November 2005 5. 9 13 (4) 31 October 2005 6. 24 23 31 October 2005 Page 25 Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 7. 24 23 identified. Confirm with CSCI plans to refurbish the kitchen, identifying proposed timescale. Replace wooden handrail by kitchen back door. Ensure that extractor fans are kept clean and free of dust so as to operate effectively Within one week 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 6 Good Practice Recommendations Organise residents personal files so as to make essential information readily and easily accessible. Make positive use of indices and cross-references, and archive or dispose of material that is not current. Consider ways in which residents can be more actively involved in developing their own care plans. Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alvechurch Road, 76 E54 S16934 Alvechurch Road 76 V245757 170805 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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