CARE HOME ADULTS 18-65
Bells Court 239 Bells Lane Druids Heath Birmingham West Midlands B14 5QH Lead Inspector
Joe O`Connor Unannounced Inspection 24th April 2006 11:30 Bells Court DS0000059595.V288994.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 Bells Court DS0000059595.V288994.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. Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 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 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) Care Through The Millennium Mr Gregory M Zhuwao Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Residents must be aged under 65 with a learning disability. 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 7:30am till 22:00pm. During the night there must be 2 waking night staff on duty. Date of last inspection 16th November 2005 Brief Description of the Service: Bells Court is a three bedroomed detached property located off a main road in the Druids Heath area of Birmingham. The service is registered to accommodate three adults with learning disabilities 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 wash hand 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 is used as a quiet room. There is a spacious kitchen/dining area that is fully equipped. A bathroom with toilet and hand wash facilities is situated on the ground floor that has handrails 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 DS0000059595.V288994.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over a day and was unannounced. All the key standards were assessed. Two service users were able to convey their views about life in the home. Service users comments were also received from comment surveys sent out prior to this inspection. Comments were also received from two visiting professionals following this visit. The Inspector spoke to one member of staff and the Registered Manager. Service users care plans and risk assessments were inspected. Staff recruitment and training records were also examined, along with a number of health and safety records. A partial tour of the premises was undertaken. The fees charged by this service range from £1,250 to £2,400 per week. What the service does well:
Service users live in premises where its external features and structure means its purpose, as a care home is not known. At the time of this inspection the service users were observed to be going out for the day to play snooker with the support from staff. The service users appeared to be relaxed and dressed in clothing that reflected their age. Two service users provided comments about the care and support they were receiving. One commented, “The staff are helpful and listen to me”. Another service user spoke of his eventual move to what is known as supported living accommodation, which would give him the opportunity to be more independent. Two professionals also spoke positively about the support being given to the service users. One stated, “ The staff will always check things out with us first before making any decisions”. Another commented that the service does well in caring for people with complex needs and there was always a relaxed atmosphere in the home. The manager has provided all three service users copies of the previous inspection report on cassette format, which they appreciated. An examination of the food records including the menus indicated the service users had access to a wide choice of healthy meals. Two service users stated they were consulted by staff about their mealtime choices. When examining the staff rota there was evidence confirming there were enough staff on duty throughout the day and night. One member of staff had left since the previous inspection and the vacancy had been filled. Information provided by the manager prior to this inspection indicated that there are sufficient numbers of staff qualified to NVQ level 2 or above. Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
While it is acknowledged that the manager has addressed a lot of the requirements from the previous inspection, there are a number that remain outstanding. These must be addressed otherwise the Commission will undertake enforcement action to ensure compliance. Care plans had been developed but these required more detailed information around how the needs of each individual were to be addressed. There was also more information needed about their routines over a twenty four hour period. One nutritional assessment examined highlighted that the service user was in need of involvement from a dietician but this had yet to be addressed. Some aspects of medication were still in need of improvement. Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 Page 7 There was no record in place of complaints that had been received by the service and the CSCI. The manager must ensure that service users have a wider range of activities available as an examination of their activity records indicated some repetition in what they did during the week. It was noted that the staff training plan provided by the manager noted that some staff were still due up to date training in adult protection. The carpet at the top of the stairs was torn and in need of repair. Some of the paintwork by the stairs was looking worn. Staff had yet to complete fire training, which is now an outstanding requirement from the previous inspection. 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 DS0000059595.V288994.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 Bells Court DS0000059595.V288994.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): 2, 3, 5 Service users have individual assessments completed by the manager with some improvements needed. Service users have a complete breakdown of their terms and conditions. Service users are provided with information about the service in an appropriate format. Improvements have been made with regard to the service’s capacity to meet the needs of the current group of service users. EVIDENCE: Since the last inspection the manager provided the CSCI copy of the Service Users Guide, which had also been given to each service user. Two service users’ files sampled shown that each service user had a breakdown of their terms and conditions of their stay and had been signed. It also confirmed whether the service users had to pay towards their transport. The manager stated he had provided each service user a cassette version of the previous inspection report and this was confirmed when talking to one who found it very helpful. Two service users spoken with provided comments about the support they were receiving. One said “ The staff are helpful they listen to me if I am worried”. Another commented “Things have been better for me since the last inspection but I’m hoping to move onto my own accommodation”. An examination of two service users care records indicated reviews had taken place involving service users with social workers. The manager confirmed that Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 Page 10 plans were in place for one service user to move into his own accommodation, which, was being supported by the forensics multi-disciplinary team. Since the previous inspection the manager had completed needs led assessments covering most aspects of service users requirements but one seen did not make any reference to one individual’s medical condition and how it was being treated. At the time of the inspection the service users were out for the majority of the day but they appeared to be relaxed and dressed appropriately for their age. Two professionals a Social Worker and Community Nurse provided comments following this inspection about how the service is meeting the needs of the service users. One stated, “Staff are knowledgeable and I would not have any hesitation in making future placements”. Another commented, “Staff are proactive and will always seek advice from the multi-disciplinary team”. “ The service users are well cared for and there is always a relaxed friendly atmosphere with staff who make you feel welcome”. Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 8, 9, 10 Service users care plans require further information around their daily routines and how specific requirements should be addressed. Service users have risk assessments in place to demonstrate how they should be supported in the home and community. Improvements have been made in maintaining service users’ confidentiality. Service users participate in monthly meetings but the minutes for these need improving. EVIDENCE: Since the last inspection the manager had developed care plans since the last inspection. There was a brief profile for each service user, which needed more detail about their routines and preferences. The care plans while identifying specific needs needed further details as to how these should be addressed. One example seen referred to a service user needing to lose weight but how this should be addressed only stated that the service user should eat less. Another care plan seen did not provide enough detail as to how the individual’s behaviour should be managed including any uses of physical intervention. Risk assessments were in place including those for falls and one file seen had a risk assessment in place for a service user should they leave the building without informing staff. There were ABC behavioural charts in place.
Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 Page 12 Two service users commented they were involved in choosing what they wanted for their meals and the activities during the week. One said there was a menu to choose their meals while another commented staff would always ask what they wanted. There was some evidence that service users meetings had taken place but not on a monthly basis. It was noted that on twice service users had chosen not to participate in these. The minutes for the meetings did not include an action plan to address any service users requests and concerns after each meeting, which was a requirement from the previous inspection. Improvements had been made since the last inspection with regards to maintaining service users’ confidentiality. An examination of the of the communication book found service users names were no longer being used only their initials and no personal care details were found. Two service users stated they were able to open their own post. Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15, 16, 17 Service users access activities in the community with staff support but the daily recording of their involvement in activities requires improving. Service users should be offered a choice of a varied programme of activities, including a holiday. Service users are not subjected to any restrictions on their daily lives. Service users are encouraged to maintain contact with their relatives. A choice of varied and nutritious meals are available to service users. EVIDENCE: At the time of this inspection all three service users were going out to participate in playing snooker. An examination of two service users’ records indicated they had until recently attended services providing supported employment. Discussion with the manager identified of the need for the service users to be offered a wider range of activities as the ones being provided tended to be repetitive such as going to the cinema, bowling, and visits to Wellesbourne Market. A member of staff commented there could be more in the way of choices with activities. One service user commented that he had attended a number of football matches involving his favourite team Aston Villa since arriving at the home in August 2005. When examining the daily records there were some entries that referred to service users going out for a
Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 Page 14 drive but did not say where. The entries also referred to trips to the cinema but no reference to the films seen and whether the service users had enjoyed their trips out. There are opportunities for service users to go out individually with staff support but the activities appear primarily to be group orientated. Two service users stated that they were all going on holiday together to Spain again later this year. There was no evidence confirming whether service users had made a choice to do this. An examination of service users’ care plans confirmed where each one had been provided with a key to their bedroom. Observations indicated there were no undue restrictions placed on service users at the time of this inspection. One service user’s file was seen, where consultation had taken place with their Community Nurse about travelling unescorted to a day service. A service user was pleased to show his recently purchased bicycle Service users records indicated they were able to maintain contact with family and friends. One service user stated he regularly sees his girlfriend during the week. Another service users has periods of home leave to see his foster carers while the third maintains contact with his father by telephone. An examination of the menus for the previous four weeks indicated service users have access to a choice of healthy meals. Two service users confirmed they were involved in choosing their meals. An examination of the food cupboards found that there was fresh fruit and vegetables and the food had been bought from reputable suppliers. Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 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 the following standard(s): 18, 19, 20 Service users access to appropriate healthcare support requires improvement ensuring their physical healthcare needs are met. Medication management requires some improvement that maintains and promotes service users’ good health. Service users receive appropriate gender care support that meets their needs. EVIDENCE: The current group of service users are all male and there are male carers available providing appropriate gender care support. Daily recording of service users activities referred to where they had completed personal care tasks including having a shower and shaving. Each service user has a manual handling assessment and these had been reviewed since the last inspection. Further examination of the care records indicated service users had access to community healthcare services including a GP, Dentist and Optician. Two service users had been referred for an assessment from a chiropodist. Service users also had access to specialist healthcare support from a Consultant Psychiatrist for medication reviews. Nutritional assessments had been completed for each service user, addressing a requirement from the previous inspection. These were reviewed every month and included a monthly record for their weight. However, one assessment seen indicated the service user was in need of input from a Dietician and so far no
Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 Page 16 action had been taken to address this. The manager stated he had sought advice from a Community Nurse involved in delivering training for individual health action plans. An examination of the visitors’ diary confirmed this was the case. Forms had been sent out the service users’ GP’s but these had so far not been completed by them. Some improvements had been made to the management of medication since the previous inspection. There was evidence confirming the manager had completed homely remedies protocols for each service user signed by their GP. An examination of the Medicines Administration Records (MAR sheets) indicated there were no gaps in recording and that outstanding amounts of medication from the period MAR sheet cycle had been carried over. Protocols were in place for the use of PRN medication but an examination of one service user’s MAR chart indicated this had not been completed and the MAR sheets did not clearly state these were PRN medication. Since the last inspection staff have undertaken training in accredited medication training with Boots Pharmacy. The medication procedure had been amended to state that any medication errors should be reported to CSCI without delay. Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 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 the following standard(s): 22, 23 Service users interests are being protected with some receiving training in protecting vulnerable adults but improvements are needed. Service users’ complaints are not adequately recorded with clear outcomes of any action taken during any investigation. EVIDENCE: The service and the CSCI have received seven complaints since the last inspection of which two were substantiated and one partly substantiated. The Registered Provider had investigated the complaints to the satisfaction of the CSCI. Two service users stated they would be able to raise any concerns with the manager. One service user has contacted the local CSCI office direct to make a complaint but said he would rather try and resolve problems with the manager and the care director for the organisation. It was noted however, that the manager had not maintained a record of the complaints received and the action taken in addressing them. An examination of the manager’s staff training records indicated most staff had completed training in adult protection although it was noted other staff members had not completed this training. The majority of staff had completed Studio III physical intervention training. The manager had addressed a requirement from the previous inspection for two signatures when dealing with service users’ personal monies. The adult protection procedure had made some reference to organisations that provide support but suggestions were made to the manager of including organisations that were local to the service. Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 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 the following standard(s): 24, 30 Service users live in a clean, homely environment with minor improvements required. EVIDENCE: A tour of the premises was undertaken and it was generally cleaned and maintained to a reasonable standard. It was noted the paintwork by the stairs was in need of touching up and there was a tear on the stairs carpet which must be addressed. It was noted that the light pull cord in the downstairs toilet was dirty and should be replaced. There were a number of toiletries belonging to service users left in the bathroom cabinet when these should be left in service users bedrooms. The manager stated that plans are in place to have the back garden re- developed. Since the last inspection the owner of the premises had taken action in ensuring each service user had a much improved reception from their television sets following work undertaken on their TV aerial sockets. Bells Court DS0000059595.V288994.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, 33, 34, 35, 36 Service users are supported by staff that are qualified to meet their needs. Staffing levels are providing service users with a continuity of care and support. Staff training has improved but the manager’s training plan must be up to date ensuring gaps in training needs are identified. Staff receives appropriate levels of supervision enabling them to undertake their duties effectively. Staff recruitment records still require improvement ensuring the protection of service user’s interests. EVIDENCE: The pre-inspection questionnaire stated that 50 of its staff team had achieved NVQ Level 2 or above. This was also confirmed when looking at the manager’s training plan. Two members of staff are currently completing NVQ Level 2. A member of staff stated she had completed training for the Learning Disability Award Framework although this was not evident on the training plan. An examination of the staff training records indicated that most staff had completed mandatory training topics including first aid, health and safety. It was noted some staff were due updated training in food hygiene. It was noted that a requirement for all staff to have fire safety training had not been addressed. Staff had completed training in topics such as autism and managing challenging behaviour. The manager’s training record was not fully up to date and it was difficult to ascertain which training was up to date. One of the assistant managers has been enrolled for the Registered Managers Award. Future training being planned is for care planning in May this year.
Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 Page 20 An examination of the staff rota indicated that there were appropriate levels of staff on duty during the day and at night. One member of staff had left the service since the last inspection due to re-locating to another part of the country. A new member of staff had commenced employment in February this year. At the time of this visit a social work student was on placement but was not part of the staff rota. The pre-inspection questionnaire stated that in the last eight weeks four individual shifts had been covered by bank staff. An examination of three staff recruitment records indicated the manager was had made some improvements in ensuring these met the regulations but it was noted one file sampled of the recently employed member of staff had only one reference when two is required. Another file seen did not have a record of the individual’s CRB check. It was noted that staff were completing new records of induction. When examining the staff records there was evidence the manager had undertaken staff supervision every two months. Bells Court DS0000059595.V288994.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, 38, 39, 41, 42 The management of the service has improved that is safeguarding service users interests in a relaxed environment. Improvements are required regarding the service’s quality assurance process. The records are generally up to date protecting service users interests. Improvements are still needed in promoting and maintaining service users’ health and safety. EVIDENCE: The Registered Manager has addressed many of the requirements from the previous inspection. He stated that staff had been supportive in working with him to make improvements identified in the last inspection report. There was evidence staff meetings had occurred since the last inspection although these should take place on a monthly basis. One member of staff spoken with stated she would be able to approach the manager if there were any problems and two service users stated the manager would help them if they had any problems. The manager stated he was no longer working for his previous employer in his capacity as a night waking carer. A representative from the organisation visits the service every month and
Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 Page 22 reports for these were available for inspection. Satisfaction surveys had been completed by service users but the manager must make these available to relatives, staff and professionals as part of its quality audit. The records held on the premises were generally up to date and locked in a secure facility. Records with regard to health and safety were satisfactory. There was written evidence confirming that the fire alarms and emergency lighting had been tested on a weekly basis. There was also evidence confirming a fire drill had occurred prior to this inspection. A risk assessment was in place for the prevention of fire. The manager had obtained product data sheets for the use and storage of COSHH materials, which was a requirement from the previous inspection. The pre-inspection questionnaire stated the testing for portable appliances had occurred during January 2005. This is now well overdue, as the test should occur annually. It was noted that a requirement for staff to undertake fire safety training had not been addressed. An examination of the accident book indicated only one had occurred since the last inspection. There was evidence confirming incidents affecting the welfare of service users were being notified to the Commission via Regulation 37 forms. Bells Court DS0000059595.V288994.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 N/A 2 2 3 3 4 N/A 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 3 STAFFING Standard No Score 31 N/A 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 N/A 3 3 2 N/A 3 2 N/A Bells Court DS0000059595.V288994.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 YA3 Regulation 14(1)(2) Requirement The Registered Person must ensure service users’ medical conditions are included in the needs led assessment and how these are being treated. The Registered Person must ensure service users care plans provide further information regarding daily routines. They must also demonstrate how the needs should be met. Outstanding Requirement. Timescale 16 January 2006 not met. The Registered Person must ensure service users’ meeting minutes document action taken following requests any requests made by service users. The Registered Person must give consideration in providing service users with a wider choice of activities. The Registered Person must ensure service users are provided the opportunity not to go on holiday together as a group. Evidence as to how
DS0000059595.V288994.R01.S.doc Timescale for action 24/05/06 2. YA6 15(1)(2) 24/05/06 3 YA8YA7 12(3) 16(2)(n) 24/05/06 4. YA13 16(2)(n) 24/05/06 5. A14 12(3) 24/06/06 Bells Court Version 5.1 Page 25 6. YA12YA16 12(3) 7. YA19 12(1)(a,b) (2) 13(1) 8. YA19 12(1)(a,b) (2) 13(1) 13(2) 9. YA20 10. YA22 22(1) 12. YA24 23(2)(b) choices have been made must be documented. The Registered Person must ensure the daily recording of service users must provide more evidence of service users responses to support and activities provided. Requirement brought forward from 16 January 2006. The Registered Person must ensure each service user has an individual health action plan in line with the D.O.H. Guidance Valuing People. Outstanding Requirement. Timescale 16 January 2006. The Registered Person must ensure that a dietician addresses individual service users dietary requirements. The Registered Person must ensure the PRN medication protocols are in place for all service users. The Registered Person must ensure it maintains a record of complaints received including the action taken and outcome of investigation. The Registered Person must ensure that the paintwork by the stairs is re-painted. The torn carpet on the stairs must be repaired as soon as possible. 16/12/06 24/05/06 24/05/06 24/05/06 24/05/06 24/05/06 Bells Court DS0000059595.V288994.R01.S.doc Version 5.1 Page 26 13. YA34 19(1)(a)(2,b) The Registered Person must 24/05/06 2 ensure staff recruitment 7(a) records include all the required documentation including two references as required in Schedules 2 & 4 Care Homes Regulations 2001. Copies of letters requesting references must be on file. Outstanding Requirement. Timescale 16 January 2006 not met. 19(1)(a)(b) 2 7(a) 18(1)(c)(i) The Registered Person must ensure staff recruitment records provide evidence of CRB checks. A training Matrix must be developed that identifies future training needs. Any gaps in training must be addressed. Outstanding Requirement. Timescale 16 January 2006 not met. The Registered Person must ensure satisfaction surveys are made available for staff, relatives and professionals. The Registered Person must ensure all staff receives fire safety training. This is now overdue. 24/05/06 14. YA34 15. YA35 24/05/06 16. YA39 24(1) 24/06/06 17. YA42 13(4) 23(4)(d) 24/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bells Court DS0000059595.V288994.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 Bells Court DS0000059595.V288994.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!
