Inspection on 28/06/06 for Bromsgrove Road, 5

This inspection was carried out on 28th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bromsgrove Road, 5 10/11/09

Bromsgrove Road, 5 02/08/07

Bromsgrove Road, 5 07/12/05

Bromsgrove Road, 5 12/09/05

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 Bromsgrove Road, 5 5 Bromsgrove Road Droitwich Spa Worcestershire WR9 8LR Lead Inspector S Davies Unannounced Inspection 28th June 2006 14.15 Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 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 Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 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. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bromsgrove Road, 5 Address 5 Bromsgrove Road Droitwich Spa Worcestershire WR9 8LR 01905 774263 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) www.macintyrecharity.org MacIntyre Care Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: 5 Bromsgrove Road is registered to provide residential care for up to 4 adults who have a learning disability, and may accommodate one person with an additional physical disability. The premises is a semi-detached property, situated on the main road on the outskirts of Droitwich Spa, within easy access of the town centre, and various amenities and facilities. The Registered Provider is MacIntyre Care, who has recently taken over this responsibility from the Royal Mencap Society. The stated purpose of the organisation is, ‘to be recommended and respected as the best provider of services for people with learning disabilities throughout the United Kingdom.’ Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this key inspection was to follow up previous requirements and recommendations, and to monitor the management and staffing arrangements and care provision at the home. Preparation for the inspection included looking at previous reports, the homes recent history and the pre inspection questionnaire completed by the acting manager. The inspection visits on 28 June and 10 August were at different times of the day and evening and were unannounced. Time was spent talking with the acting manager, all members of staff and the four service users, who all indicated they were happy to be living and working at 5 Bromsgrove Road. The care records of two service users were seen, and delivery of care and support was discussed with their key workers and other staff members. Records kept in respect of food provision and a sample of the home’s written policies and procedures were also checked. What the service does well: The home has a lively and friendly atmosphere. Service users are encouraged to take part in the everyday activities of the home and to express their views and choices, which are respected. Everyone has a varied programme of college, day placement and leisure activities. The inspection was carried out at times when most service users were at home and their happy demeanour throughout, with much laughter and affection, was testimony to the continuing progress being made in this service. The staff team is now almost complete, and an acting manager is in post with a view to registration. The staff are committed and well motivated, morale is good, and they provide a high standard of support for service users. Staff are receiving regular supervision, are completing foundation training and possess a good general understanding of service users needs. Risk assessments are in place, and due for review and upgrading within the new providers procedures. Staff are clear about their roles and responsibilities. The records system is being reorganised and brought up to date to meet current standards. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 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 the following standard(s): 1,2,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. When revision work is completed, prospective service users will have access to good information about the home and the opportunity to make an informed choice about where to live. EVIDENCE: Feedback has been given on a draft service users guide, and a final version is awaited, therefore the requirement about this is being repeated. A version service users can use needs to be developed. The most recent service user had transferred back into her home area from an out of county placement. Most staff in the home joined after she moved in so were unable to comment on her admission arrangements, but information on the service users records confirm that admission procedures had been followed to make sure the service was suited to her and able to meet her needs. A community care assessment had been carried out and the service user had opportunities to visit the home with her family, prior to reaching a decision on moving in. Her family comment that the process was tailored and timed to suit her needs and circumstances with a placement decision reached only after several months’ careful introductions. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 9 The service user has limited speech so it is not possible to discuss her experiences with her, but her demeanour, interaction with staff and ready smiles during the inspection showed she feels at ease in her new home. Her family carers were asked for their views, they feel her needs are understood and being met, that she has settled well and is happy and making good progress here. Where contracts with the previous provider are still in place, these need to be replaced with contracts with the new provider. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The ways in which care and support needs are assessed and met are being developed so that opportunities for services users to be involved and make choices are given priority. EVIDENCE: Two service user plans were seen and good care practice observed during the inspection. Records and observation of practice show service users are supported to make their own choices and decisions about their daily lives, for example one service user explained how she had chosen the décor in her bedroom, while all service users are helped to choose their own meals and plan the meals for the week. Staff are working to improve communication with varied ways for service users to express their own views, for example with the use of photographs showing main ingredients to help plan meals. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 11 One plan, in this provider’s style, is generally person centred, well constructed and consistent. The other is a less coordinated record of the service users care, which reflects the many staff and management changes at this home and needs improvement. The acting manager is attending to this using the first example as the model. Staff have been getting to know service users and contribute to daily records. Work has already begun on improving the care records, and staff are being shown good recording practice. Training is being arranged in person centred planning and good recording practice, so that they can develop sound and effective service user plans written from the service users point of view. A key working system has been introduced now the team is almost complete and staffing stabilised. The two service users’ key workers spoken to were familiar with the service users’ needs, committed to improving their own skill and understanding through training, and keen to help service users’ enjoy a good quality of life. Staff and service users get on well with one another, showing warmth, humour, patience and respect, and staff communicate effectively with service users using appropriate methods including Makaton symbols. Service users with limited communication are having individual communication assessments. A special communication aid was being introduced for one service user during the inspection, based on a book of personal photos with a voice recording facility, which is a promising new initiative. Staff training is planned to develop communication skills. Risk assessments are in place, but still in the former provider’s style. These need to be updated, and it would be good practice to convert as soon as possible to the new provider’s system which looks at risk across all areas of day to day living. The acting manager recognises the need to manage risk in a positive way by helping people develop wherever possible through identifying goals and learning new skills. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy good opportunities to participate in activities, to their liking, in the home and the community. EVIDENCE: Records, observation and discussion show service users follow a varied range of individual activities in and outside the home, meeting friends and family and joining activities in the local community, as seen in the many photographs on display and in personal records. Service users spend their time on a mix of activities including college, day centres, work and leisure pursuits. Staff also gather information about local activities and places of interest to share with and support each service user in planning their individual time. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 13 During the inspection three service users were busy with both household activities and their own pursuits, playing music, knitting, crayoning and learning to blow bubbles with staff, with a sense of fun, achievement, and much warmth and laughter. A popular event is a ‘ladies night in’, when all enjoy an evening of beauty therapy, manicures, hairdressing and makeup. There is a good understanding of complex personal needs and the value of appropriate activities. One service user with mental health needs is well supported to continue the highly active, stimulating and engaged lifestyle she enjoys, with strong community ties. She is still enthusiastically pursuing new goals, keeping her young-at-heart and socially in touch. Another service user with different mental health needs receives understanding support from staff while consideration is being given to finding services best suited to her needs. Staff show skill in balancing a respect for her privacy while maintaining discreet contact and consistent oversight, offering encouragement and support to engage her in activities such as going out together for a meal to encourage both social activity and nourishment. Two service users with more limited communication and abilities receive more direct support in and outside the home to enjoy a wide range of activities and extend their interests and skills - for example, returning during the inspection excited and animated from a theatre production of Chitty Chitty Bang Bang. Sample menus show a generally balanced, healthy diet is aimed for. Service users are involved in all aspects of meals, staff supporting them to choose what they would like to eat and encouraging them to take part in shopping and meal preparation. Mealtimes are a social occasion but are flexible to fit in with other activities. Consideration is being given to ways of improving communication for example with photos of meals and key ingredients, to extend real choice. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs of service users are being met in a responsible manner but some improvements in planning, recording and staff training need to be fully implemented. EVIDENCE: Some service user plans need upgrading to give staff a full picture of service users needs and how they are to be met, and this is planned (see outcome group 2, Individual needs and choices). Recent input is better on personal needs and preferences, including daily routines, providing more information for staff to enable them to support service users in the way they need and prefer. It is already evident talking to staff and observing care practice, that they have a good understanding of service users as individuals, their day to day care and support needs and personal choices. Improved records will help them to build on this good start. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 15 Health action plans are still being completed, this work needs to be coordinated with the upgrading of service user plans. Although there is evidence in records that service users access NHS services and receive regular optical, dental, and hearing check ups, this information has either not been consistently recorded for all service users or, not all service users are benefiting from all checks they are entitled to. Records should be designed to support good health care practice so that any oversights and omissions are evident and can be quickly put right. As service user plans are brought up to date they should include more systematic evidence that known health needs are kept under review, input and progress is monitored and recorded, and attention is given to preventative health care. Information on health and personal care should be integrated so that any impact on service users lives is clear and can be acted upon promptly. Feedback from two GPs provides evidence that health care providers do have confidence in this service, as they consider service users known health care needs are recognised and being addressed. The acting manager has relevant experience and skills in working with people who have diagnosed mental health needs, and has established effective liaison with relevant professional agencies. In addition to general care practice the training programme needs to include the specific knowledge and skills to meet special needs such as epilepsy, dementia, and mental health problems. Staff should also have a good understanding of the normal ageing process and the needs associated with this. There is a medication policy and procedure in place, and observation of one experienced staff administering medication showed a clear understanding of the procedures with a sound approach to the management, storage and administration of medication supported by clear and effective records. An error was reported and responded to appropriately. However, while the acting manager is careful and conscientious she has limited experience of medication administration responsibilities and has only recently undertaken recognised medication training herself. She now needs to consolidate this training and develop the confidence to lead and support her staff team, and it would be good practice for her line manager to provide additional support and supervision on medication matters while she achieves this. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to express their views and opinions but those with communication difficulties could benefit from more support. Protection from abuse and neglect will be more assured when all staff have undertaken the relevant training. EVIDENCE: There have been no complaints recorded since the previous inspection, and no survey respondents indicated that they had any concerns. A satisfactory complaints procedure is in place at the home, and service users are encouraged and enabled to express their views and opinions. However this procedure is not yet produced in alternative formats suited to service users abilities, and consideration needs to be given to this. In view of the communication difficulties faced by some service users, it would be good practice to consider the benefits of advocacy, and the complaints procedure needs to acknowledge how staff respond to other indicators that service users may be distressed or have concerns, to ensure they have the same opportunities to make their voices, and any complaints, heard. Staff demonstrate an awareness of the issues relating to abuse. The need for further staff training to ensure the protection of service users, identified at the previous inspection, has been partially met with training on the management of challenging behaviour and use of restraint, and there is an ongoing Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 17 programme of training including forthcoming POVA training, to make sure this is extended to all new staff. All staff need to understand the local procedures for responding to suspicions of abuse. There are procedures in place to record and track the administration of service users finances and prevent abuse. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and comfortable home but it would benefit from some improvements. EVIDENCE: The communal areas of the home are freshly decorated and comfortably furnished. There is a pleasant lounge/dining room, recently refurbished and redecorated to service users choice, for their use. However there is no separate area other than service users own bedrooms where they can sit or receive visitors in private. The home is clean and fresh. There is one bathroom and two separate toilets, one on the first floor and one on the ground floor, for service users; the latter is shared with staff. There is one bathroom with an overbath shower recently installed, the bath is due for upgrading. All service users are able to use this facility at present but may need more specialist facilities in due course as a result of increasing age and Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 19 more limited mobility, so it would be good practice to take this into account when upgrading to new equipment. The bathroom décor is basic and would also benefit from upgrading to a more comfortable domestic standard. Washbasins have recently been installed in service users bedrooms, one service user was pleased with hers. Bedrooms are comfortable, individually decorated according to service users personal choice and personalised. Outside is a terraced garden, on a bank so not readily accessible to service users, and a paved area where service users enjoy sitting and eating out in fine weather. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a new and enthusiastic staff team who already have a good insight into the complex and varied needs of the service users. Training, which is being planned, will help them to develop their knowledge and skills. EVIDENCE: Further changes mean the home again has a new team of staff, who are beginning to work effectively together for the benefit of service users, some former staff remain which provides for continuity but some are new to this work. There is high morale with a strong shared commitment to provide a quality service which listens and responds to service users. All staff are keen and well motivated, and show a good general understanding of service users needs. There remains some reliance on agency staff to ensure numbers on duty are sufficient to meet service users needs, but as far as possible regular agency staff are used who are familiar with the service and service users, improving continuity and confidence. Recruitment is ongoing, with the aim of having a full team established soon so that progress can be made with team building and staff and service development. Staff are deployed flexibly and effectively enabling both responsiveness to need and spontaneity in activities Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 21 when required. A full training programme is being established providing staff with the basic competencies necessary for them to be effective in their work, and is also addressing the need for more specialist training such as communication. Staff are working through their induction training, and keen to progress to the next training level, working towards the Certificate in Working with People with Learning Disabilities and onwards to the National Vocational Qualification programme. Staff spoken to were very clear about their roles and responsibilities. Service users in this home have complex and varied needs. While staff show a good insight into these needs, the acting manager is well aware of the need for a full programme of training which will ensure staff have all the knowledge and skills they need to support these service users appropriately, and this is being planned. Regular staff meetings have been reintroduced and are minuted, and staff report that they receive regular supervision and are given appropriate support. Supervision sessions are recorded in writing. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 22 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): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management arrangements at the home are being addressed but developments are necessary to ensure long-term stability and improvements that reflect service users’ views. EVIDENCE: There is currently no registered manager, but an acting manager has recently been appointed with a view to registration. No quality assurance procedure is yet in place, and this must now be addressed. One referral has been received confirming familiarity with procedures for notifying the Commission about events affecting service users’ well-being. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 23 Up to date policies and procedures are now in place although it is unclear if staff have yet read or are familiar with these, and systems need to be put in place enabling the manager to check such matters. The acting manager has been spending time so far familiarising herself with the service, meeting service users, staff, and service users relatives, and attending an extensive internal management induction programme. She has almost completed an audit of records and office systems, and is upgrading these to meet the needs of this service. Sample checks show health and safety, administrative and maintenance procedures are being brought up to date with routine checks carried out as required, together with staff training in safe working practices. The new manager has NVQ4 in care management and the Registered Managers Award, as required for registration, and her application is awaited. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 x 4 3 5 2 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 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 2 x 1 x x 3 x Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 6 Requirement The statement of purpose and the service users guide must be revised to accurately reflect the services and facilities available, and the service users guide should be made available in a format suited to the service users This was not completed by the date required for action and is repeated for this inspection 2. YA5 15 The contract/statement of terms and conditions must be amended to reflect the organisational changes This was not completed by the date required for action and is repeated for this inspection 3 YA6 15 Service user plans must be established for all service users and regularly reviewed, which are well structured to provide complete and up to date information from the service users perspective, about their personal and health needs, DS0000064301.V300197.R01.S.doc Timescale for action 08/12/06 08/12/06 08/12/06 Bromsgrove Road, 5 Version 5.2 Page 26 4 YA9 13 5. YA18 18 abilities and aspirations and how these are to be met Risk assessments must be carried out, kept under review and updated as part of an enabling risk management strategy which supports service users to develop skills and achieve optimum independence Training must be provided for all staff to enable them to meet all service users identified special needs including mental health needs, dementia and epilepsy All staff must attend recognised training in the handling and administration of medication, before taking responsibility for administering medication 08/12/06 08/12/06 6 YA20 13 08/09/06 7. YA23 13 This is an immediate and ongoing requirement Training must be provided for all 08/12/06 staff on all aspects of abuse and the protection of vulnerable adults, including local procedures for responding to suspicion of abuse. This requirement has been partially met and is therefore repeated 8. YA32 18 Staff training needs must be assessed and all staff provided with an individual training profile, with a full programme of training appropriate to the needs of this service user group, including the needs associated with ageing, and the tasks they are expected to carry out A full quality assurance system must be introduced and implemented, with a copy of the report on the outcome of any DS0000064301.V300197.R01.S.doc 08/12/06 9. YA39 24 31/10/06 Bromsgrove Road, 5 Version 5.2 Page 27 10. YA40 12 surveys made available to the Commission Arrangements must be made to ensure that staff understand and carry out effectively the homes policies and procedures, so as to make proper provision for the health and welfare of service users. An application for registration of the manager must be submitted to the Commission 08/12/06 11. YA37 8 08/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Further development of Person Centred Planning should be undertaken by staff at the home, with consideration given to the layout of service user plans, so that information is easy to use, and makes sense as a picture of the whole person, their hopes and plans, and the help they need to live life to the full. 2. YA19 Health Action Plans should be completed for all service users Consideration should be given to the benefits of an advocacy service for service users with limited communication, and to including a statement in the complaints procedure showing how staff aim to respond to behavioural indicators that service users may have concerns with the service Consideration should be given to providing additional supervision and support for the manager on managing medication in the home, with the area manager retaining DS0000064301.V300197.R01.S.doc Version 5.2 Page 28 3 YA22 4. YA20 Bromsgrove Road, 5 5. 6. YA24 YA33 overall responsibility, until she is fully trained and has gained sufficient experience in managing medication systems in this setting Consideration should be given to the possible future need for specialist bathing facilities suited to the needs of older service users with restricted mobility The staffing arrangements at the home should ensure that the use of agency staff is limited. Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Bromsgrove Road, 5 DS0000064301.V300197.R01.S.doc Version 5.2 Page 30 - 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!