Inspection on 02/08/05 for Bells Court

This inspection was carried out on 2nd August 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bells Court 24/04/06

Bells Court 16/11/05

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 Bells Court 239 Bells Lane Druids Heath Birmingham B14 5QH Lead Inspector Joe OConnor Unannounced 2 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. Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bells Court Address 239 Bells Lane Druids Heath Birmingham West Midlands B14 5QH 0121 459 1883 0121 459 2249 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) Care Through The Millenium Mr Gregory M Zhuwao Care Home 3 Category(ies) of Younger Adults, Learning Disability [3] registration, with number of places Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 with a learning disability. 2. In addition to the manager a minimum of one other suitably qualified and experienced member of staff must be provided throughout the waking day, that is 7:30 till 22.00. During the night there must be 2 awake night staff on duty. Date of last inspection First Inspection Brief Description of the Service: Bells Court is a three bedroomed detached property located off a main road in the the Druids Heath area of Birmingham. The service is registered to accommodate three adults with learning disabilites providing residential care and a day service. Bells Court is close to local bus routes for Birmingham, Shirley and Solihull. It is also close to local amenities including the Maypole Shopping Centre. The premises consist of three single bedrooms with en-suite shower, toilet and washhand basins located on the first floor. On the same level there is a laundry that has a washing machine with a sluice programme. The ground floor has two comfortable lounges, one of which will be used as a quiet room. There is a spacious kitchen/dining area that is fully equipped. A bathroom with toilet and hand wash facilities are situated on the ground floor that has hand rails fitted to assist with access. An office is also situated on the ground floor. The property is accessed via a service road that is altered by high fencing, shrubs and ornamental trees providing security and privacy. There is a gate to the front of the property and is accessed by an electronic keypad. This leads into a driveway. Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the service since it was first registered in May 2005. The visit took place over one day and was unannounced. The Inspector had opportunity to talk to two service users, both had only been living in the home for a few weeks and one member of staff. The Inspector also had opportunity to talk to the Care Director of the organisation. A limited tour of the premises was undertaken. Service users care plans and risk assessments were inspected. Staff recruitment records were also examined and a number of health and safety records were also examined and a number of health and safety records were also sampled. What the service does well: Service users live in premises where its external features are similar in design and structure to that of neighbouring properties and its purpose as a care home is not distinguishable. Service users were observed to receive friendly and professional support from care staff. Comments were received from service users who were new arrivals to the service. One service user commented “ I have more freedom here unlike where I was living previously.” Another stated “I am happy here the staff are very good”. “We have a choice of what we want to eat and where to go”. Service users were found to be well cared for and dressed appropriately for the climate of the day. The atmosphere during this visit was friendly and relaxed. Service users expressed satisfaction with the meals provided and the food records indicated there was a varied choice. Transport is provided for service users to go out in the community such as cinema, local pubs ten pin bowling and day trips to places such as Warwick Castle and Drayton Manor Park. Service users are able to spend as they please with no rigid rules or routines. An examination of service users care records found that service users were only placed in the service once an assessment and initial care plan had been completed by a social worker. Initial assessments were also completed by one of the care director for the organisation. One service user had made a number of visits to the service to see if it met his needs. Service users care records confirmed that they had access to a range of healthcare professionals such as GP, optician and dentist. The service has developed good relationships with specialist professional support services within the area of learning disability and mental health. Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Medication management was found to require significant improvement and action must be taken to ensure that all medication received is booked onto the Medicines Administration Records or MAR charts as they are known. The medication procedure needs to be amended so that it states any medication errors are reported to the CSCI and have details of the supplying pharmacy. A list of staff signatures is required of staff trained to administer medication. The staff rota must clearly state the hours worked by staff and it must also refer to the hours they are contracted to work. Staff records must have evidence to confirm that CRB checks for new staff had been applied for. While it is acknowledged that the service has only been up and running for a few months some improvements with service users care records are required. Nutrition assessments must be completed to ensure any issues around service users’ dietary needs are addressed. One care plan sampled of one service user who was the first to arrive at the service did not have a detailed picture with regard to his likes and dislikes, along with his daily routine. All accidents must be reported to the Commission without delay. The complaints procedure that is on the premises must state that the CSCI can be contacted at anytime during the complaints process, and that no one will be victimised for making a complaint. Service users records must document that service users have been offered a key to their bedroom and the reasons if this has been declined. The daily recording of service users must provide more evidence of what kind of domestic tasks completed by service users. It must also refer to service users’ responses to activities e.g. did they enjoy a particular trip or activity. Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 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. Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 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 standard(s) 2, 3, 4 Service users needs are assessed prior to admission to the service covering all aspects of their daily living activities. The needs of the current group of service users are being met through the development of detailed care records and with staff that demonstrates an understanding of service users needs. Service users have the opportunity to visit the service prior to admission but records of trial visits must be maintained. EVIDENCE: At the time of this inspection there were three service users two who had only been accommodated for a few weeks. Comments received from the service users were positive. One stated that he had been living in another service in Shropshire where he felt subjected to a lot of unnecessary rules. “Here you have more freedom” was his main view. Another service user stated that the staff were helpful and were nice when they spoke to him. Two relatives who were visiting one of the service users felt the accommodation was excellent. A sample of service users records found that pre-admission assessments had been completed by social workers along with initial care plans. Both service users spoken with stated that social workers had been involved in their admission to the service. There was additional evidence to confirm that the manager had also been undertaking assessments when the service users had moved in. It was also found that the service had also completed initial assessments following referrals made by social services. One service user who had been living in the service since it first opened stated that he had made a Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 10 number of visits to try the accommodation prior to moving in but there were no records on file to confirm this. The service has an admissions procedure. Discussion with the Care Director and member of staff found they had a very good understanding about the needs of the service users in their care. Service users appeared to be well presented and dressed in clothing that was appropriate to their age. Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 11 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, 8, 9 How service users needs are to be met are currently being developed within individual care plans but improvements are required to ensure the care plans state how service users goals and daily routines are to be addressed with regard to their daily routine on a day to day basis. Service users have risk assessments in place that ensure staff are aware of how service users are to be escorted in the community. EVIDENCE: A sample of two service users care plans had information about the service user in the form of a pen picture. There were areas of needs to be met in areas such as physical and mental health and some references to service users dietary preferences. While it is acknowledged that the care plans are in the early ages of development there is a need for the care plans to refer how service users preferred lifestyles and activities are to be achieved. It was noted that the care plans referred to service users requiring prompting with personal care but they did not specify in what areas. The Care Director stated that each service user would have a three monthly keyworker supervision session that involves them in the review of their care plan. One service user commented that the manager worked with him to start his care plan. Another stated that the Care Director did his care plan and talked about what he would like to do Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 12 Risk assessments were in place that covered topics such as managing challenging behaviour and escorting service users when going out. There were also assessments in place for preventing falls. Service users stated that they were consulted by staff about where they would like to go out. There are no service users meetings as such as many of the decision making process is done on an informal basis. The Care Director stated that one of the aims of the service was to run it as though everyone was part of a family environment where everyone is involved in making decisions. A member of staff was observed discussing with a service user their teatime meal choice. One service user’s care records found that an advocate had been involved in assisting him to move from his previous accommodation. In conversation a service user stated that he had his own bank account and that staff supported him to manage make withdrawals. Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 13 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, 14, 15, 16, 17 Service users with staff support are able to access activities in the community. Service users maintain good relationships with staff and have contact from relatives. There are no unnecessary restrictions affecting service users daily routine, but service users must be given the opportunity to have a key to their bedroom. Service users have access to wholesome nutritious meals with menus with choices available. Daily recording of service users do not provide a full picture of their daily routines and their responses to support received from staff. EVIDENCE: At the time of this inspection two service users were going out for a pub lunch with staff. One service user stated that he likes to go Bowling and shopping. Another service user who had only recently moved in stated that he too enjoyed going bowling but would like to see his favourite football team Aston Villa during midweek home games. A sample of service users records found there had been leisure activities organised such as trips out to Stratford Upon Avon and Drayton Manor Park. Both service users stated they were looking forward to a holiday in Spain later this year. The service employs a qualified Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 14 Counsellor who involves service users in relaxation therapies including the use of exercises such as Tai Chi. Observations at the time of this inspection found that this is very much the service users’ own home with no unnecessary restrictions. One service user stated he had a key to his bedroom but another stated he was not offered one on his arrival. At the time of this inspection one service user was observed to wash up and stated he did his own laundry. However, the daily recording of service users did not provide enough detail to as to the kind of domestic tasks completed during the week. For example one entry referred to a service user completing his household chores but did not specify what had been done. There was also no evidence to confirm whether service users had enjoyed their activities. Service users have access to menus that provided a nutritious balanced diet. Records of meals eaten by service users are maintained. Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Service users care is flexible and supports their individual needs. Service users healthcare is appropriate by staff promoting and maintaining good health. Service users nutritional needs are not assessed on admission. Medication management is in need of improvement to ensure the promotion and maintenance of service users’ health. EVIDENCE: Care records sampled indicated where service users had completed personal care tasks. Each service user has a manual handling assessment. Service users have been registered with a GP and they also have access to a dentist and optician. It was evident that good relationships are maintained with other multi disciplinary services such as community nurse and consultant psychiatrist provided by the Primary Care Learning Disability Trust. One service user had been referred to forensic services as part of his Care Programme Approach within the legal requirements of the 1983 Mental Health Act. It was noted that nutritional assessments forms on the service users records had not been completed and the manager must ensure these are completed as part of their nutritional well being. The management of medication needed improving. The Medicines Administration Records (MAR charts) did not have details of the amount of medication received and these had not been signed. One service user who was prescribed Clozapine tablets at different strengths had the details of the Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 16 medication written in one section of the MAR chart when these should have been entered separately. There was not a list of staff signatures of those trained to administer medication. Staff had not received accredited medication training. Photographs of the service users were required for the MAR charts. There were written protocols in place for the use of PRN or as required medication. The medication procedure was found to require some amending to include any medication errors must be reported to the CSCI and details of the supplying pharmacist. Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 17 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 Service users have access to a complaints procedure, which will require some amending. Service users welfare is protected but the prevention of abuse for vulnerable adults training must be undertaken. There is an adult protection policy and procedure that needs some amending. EVIDENCE: A complaints procedure is available and a number of amendments were required to include assurances that no one will be victimised for making complaint and that the CSCI can be contacted at anytime during the complaints visit. Two service users stated that they felt staff and the manager would listen to their concerns. One member of staff gave satisfactory responses to questions with regard to protecting service users from abuse and how any complaints would be addressed. The member of staff concerned had received training in adult protection and the Care Director has booked training in adult protection for all staff for the remainder of this year. The manager has a copy of the Multi Agency Guidelines published by Birmingham Social Care & Health. There is an adult protection policy and procedure but some amendments are required to state that staff will receive training and that a list of organisations providing support to service users must be in place. Bells Court E54 S59595 Bells Court V242105 020805 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, 27, 30 Service users live in a homely non institutional environment that is decorated and furnished to a high standard. Service users are able to move freely around the premises without any hazards. Infection control practices maintain service users health and safety. Service users have suitable facilities for bathing including en-suite showers in all bedrooms. EVIDENCE: The premises were found to be decorated and supplied with furniture and fittings to a high standard. Two service users commented that they thought it was clean and tidy. Service users were observed to move freely around the property. There is a separate laundry area that includes a washing machine with a sluice programme. There are procedures in place for the control of infection. Although a limited tour of the premises was undertaken, each service user has have en-suite shower facilities with toilet and wash hand basins. There is a corner bathroom suite on the ground floor with a toilet and wash hand basin. The bath has a grab rail to assist with access. Disposable towels and soap dispensers were in place. Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 Service users receive support from staff that have job descriptions setting out their role and responsibilities. Service users are supported by staff that demonstrates an understanding of the needs of service users in their care. The organisation is developing appropriate training to all staff employed to enhance their development and that is relevant to the needs of the current service user group. Staffing levels provide service users with continuity of care during the day but not always during the night. Staff recruitment records are generally maintained to an acceptable standard with some improvements required. EVIDENCE: Staff demonstrated an understanding around the needs of service users and positive interactions were observed. Observations indicated that service users were comfortable with staff supporting them. Since the service has been registered in May this year the levels of staffing have increased as new service users have moved in. Currently there are three members of staff on duty throughout the day from 8:00am-23:00pm, with a senior member of staff also on duty. There is also a team of bank staff available to cover any additional shifts. The staff rota states there should be two night waking staff on duty but an examination of the staff rota found that on occasions there was only one night waking staff on duty and the organisation must be mindful of its condition of registration. The staff rota did not clearly state that hours worked by staff and their contracted hours. The Care Director stated that she was due Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 20 to interview applicants for the post of team leader and had two new members of staff due to commence employment subject to CRB checks. Staff recruitment records were generally satisfactory. There was evidence of job application forms, proof of ID, passport, job description, two references and some evidence of qualifications including training certificates. Medical questionnaires were also in place. Each staff file examined found that staff had completed or near completed induction records. However, it was noted there was no evidence to confirm when applications had been made for CRB checks, nor were there any contracts of terms and conditions. During the inspection the Care Director provided a copy of a letter written by the training manager of South Birmingham Primary Care Learning Disability Trust of training that was being arranged with dates yet to be confirmed. The topics being covered were epilepsy awareness, physical intervention, autism, adult protection, supervision and forensic work. The Care Director also stated that all staff had been registered to undertake training towards the Learning Disability Award Framework (LDAF). Of the three staff files sampled two had certificates to confirm that one staff was qualified to NVQ Level 2 and another to NVQ Level 3. The Care Director is required to ensure that all staff have copies of the General Social Care Council Code of Conduct. Bells Court E54 S59595 Bells Court V242105 020805 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) 38, 41, 42 There is a relaxed and friendly atmosphere that benefits service users and staff. Service users interests are protected with records that are generally up to date. Service users’ health and safety is promoted and protected with some improvements required. EVIDENCE: The inspection was undertaken with the Care Director of the organisation who was able to provide a good understanding of the needs of the service users in her care. Comments made were received positively and there was evident commitment to improve practice. Service users spoken with stated they would be able to approach the manager and staff if they had any concerns. The atmosphere at the time of this visit was found to be relaxed and friendly. The records held on the premises were found to a certain extent up to date and locked in a secure facility. Records with regard to health and safety were found to be satisfactory. There was evidence that the fire alarms were being tested on a weekly basis and the emergency lighting every month. A fire drill had occurred prior to this Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 22 inspection. There was also evidence to confirm that the gas and electrical equipment had recently been serviced. The accident book was examined and it was noted that there had been three accidents since the service was registered but these had not been reported to the Commission via Regulation 37 notification. The kitchen was found to be clean and tidy and it was noted that a daily record was being maintained for the temperatures of the refrigerator and freezers. Bells Court E54 S59595 Bells Court V242105 020805 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 x 3 3 2 x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 2 3 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bells Court Score 2 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 x x 3 2 x E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 24 No 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 4 Regulation 14(1) Requirement The Registered Person must ensure that in future it maintains records of prospective service users trial visits to the service. The Registered Person must ensure service users care plans clearly set out how the needs of service users are to be met. They must also provide a full picture of service users daily routines. The Registered Person must ensure the daily recording of service users must provide more evidence of service users responses to support and activities provided. It must also refer to what kind of domestic tasks had been completed. Service users care plans must provide evidence where service users have been consulted with regard to having a key to their bedroom. The Registered Person must ensure that nutritional screening assessments have been completed. The Registered Person must ensure that medication quantity and dosage of medication Timescale for action 8 August 2005 8 October 2005 2. 6 15(1) 3. 16 12(3) 9 August 2005 4. 16 12(3) 8 September 2005 8 September 2005 8 September 2005 Page 25 5. 18 12(1)(a) (b) 13(2) 6. 20 Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 7. 20 13(2) 8. 20 13(2) 9. 22 22(1) 10. 23 13(6) 11. 33 18(1)(a) 12. 33 18(1)(a) Schedule 4 (7) 13. 35 14. 42 19(1)(a) (b)(i) Schedule 2 7(a) 13(4) 37(1) received is booked in onto the Medicines Administration Records (MAR Charts) The Registered Person must ensure that medication with different strengths must be written on separate entries on the MAR sheets. The medication procedure must be amended to include that any medication errors must be reported to the CSCI. It must also have details of the supplying pharmacist. The complaints procedure must be amended to state that the CSCI can be contacted at anytime during the complaints process and provide assurance that no one will be victimised for making a complaint. The Registered Person must ensure that the adult protection policy and procedure refers to organisations who provide support to service users and an outline of training available to staff. The Registered Person must ensure that there were two night waking members of staff on duty during throughout the night. The Registered Person must ensure the staff rota states the following: Person in charge Hours worked Handovers Must include record whether rota actually worked. The Registered Person must ensure staff recruitment records must provide evidence of CRB applications. The Registered Person must ensure that CSCI is notified of all issues in relation to Regulation 37. 8 September 2005 8 September 2005 8 September 2005 8 September 2005 8 September 2005 8 September 2005 8 September 2005 8 September 2005 Page 26 Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 Page 27 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 Bells Court E54 S59595 Bells Court V242105 020805 Stage 4.doc Version 1.40 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!