Inspection on 07/12/05 for Bromsgrove Road, 5

This inspection was carried out on 7th December 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 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 12 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 28/06/06

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 7th December 2005 12:00 Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 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.V271432.R01.S.doc Version 5.0 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.V271432.R01.S.doc Version 5.0 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.macintyre-care.org MacIntyre Care Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 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 include 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.V271432.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine unannounced inspection was to follow up previous requirements and recommendations, and to monitor the staffing arrangements and care provision at the home. The inspection was undertaken from late afternoon to mid evening. The acting care manager was on a training course at the time of the visit. Time was spent talking with 3 members of staff and 4 service users, who all indicated they were happy to be living and working at 5, Bromsgrove Road. The care records of 2 service users were seen, and delivery of care and support was discussed with 2 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 friendly and happy atmosphere, and service users are involved in the daily routines within the home. Everyone has a varied programme of college, day placement and leisure activities. The staff team is fairly new and the morale is good. There is evidence of a commitment to their work. They are well motivated, and provide a high standard of support for service users. Staff are completing induction training and able to demonstrate a good understanding of the needs of service users. Risk assessments are in place, and kept under review. Staff are clear about their roles and responsibilities. The records seen were well maintained and up to date. Service users are encouraged to take part in the everyday running of the home and to voice their opinions, and their choices are respected. Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The Statement of Purpose, the Service Users Guide and the Terms and Conditions of Residence should fully reflect the new organisation which now has responsibility for the home. The service users should each have their own signed and dated copy of the terms and conditions of residence . The Home’s written policies and procedures should be reviewed to make sure they comply with current requirements, are up to date, and cover all the topics set out in Appendix 3 of the National Minimum Standards. They need to be dated and kept under review to make sure that they continue to be relevant and appropriate to this service. The home has been without a registered manager for over 12 months, and although the acting manager has been coping very well with the day to day running of the home, the situation now needs to be resolved. Please contact the provider for advice of actions taken in response to this Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 7 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.V271432.R01.S.doc Version 5.0 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 Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 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): 1, 2 and 5 At the last inspection documentation in place to provide information to service users or their representative needed further development, to ensure that relevant details enable an appropriate decision about their future care needs. The action needed has subsequently been discussed with the Regional Manager and the outcome is currently awaited. The admissions procedure is carefully followed, with proposed admissions planned very thoroughly to ensure an appropriate decision by both staff at the home and the service user. Documentation on file provided evidence that prospective users’ individual needs and aspirations were fully assessed prior to admission and kept under subsequent review. EVIDENCE: A Statement of Purpose and the Service Users Guide have been produced by MacIntyre Care, and provide much of the information identified by this standard. Further amendments necessary to ensure clarity have been discussed with the Regional Manager since the last inspection, and amended versions are awaited. Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 10 The Terms and Conditions of residence have been updated and put in place for some service users, signed and dated by all parties. These must now be completed for every service user. There have been no further admissions since the previous inspection. Community care assessments provided by a social worker were included on each service user’s records, addressing individual aspirations and needs, and providing the basis for establishing each service user’s individual Plan. Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 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 and 9 The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. Service users’ plans are still being developed, which include appropriate risk management strategies enabling a responsible approach to the risks associated with the various activities of daily living. Consideration needs to be given to the layout of service user plans, so that information is gathered and presented in a way that is easy to find and 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. EVIDENCE: Each service user has an individual plan of care based on the initial assessment. This is regularly reviewed and updated. Service users attend and are encouraged to take a full a part in the review process, where their needs and individual preferences are identified. Service users talked about ways they take part in the daily life of the home. They have regular weekly meetings supported by a staff member, where they Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 12 are encouraged to raise and discuss any matters that concern them, and plans are made for such things as food, activities and the accommodation. Service users are also reminded at these meetings that they can raise and discuss here or privately, any other concerns they may have. Risk assessments are completed as required, in relation to the premises, and to all aspects of service users’ day to day lives. These are dated and signed, and regularly reviewed to make sure they remain up to date and are used to help promote an independent lifestyle. Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 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): 16 and 17 Service users are encouraged to take part in the household’s daily routines. Everyone is involved in planning their daily activities within and outside the home, but there is no record to show expectations about the nature and level of contributions. The limited statement of house rules needs revision to clearly specify the rights and responsibilities of group living and how these are to be met. Both the service user guide and the service user plan need to be clear about individual contributions to housekeeping tasks. The menu showed a range of healthy and appetising evening meals planned, but there was not enough recorded information to show whether individual service users diets were healthily balanced for their needs. EVIDENCE: Service users said they are helped to take part in all the activities of daily living at the home. However this process is not recorded so it is not clear how this works in practice, either generally or for individual service users. Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 14 The brief statement of house rules is limited to a short list and does not specify rights and responsibilities or how these are to be recognised and respected. There was a menu showing the main meal for each day, but there was no other record of food provided so this information was incomplete. A record needs to be kept showing the actual meal, with accompaniments, that each service user has for every mealtime, as well as the availability of drinks and snacks, fruit and so on, so that it is possible to monitor the adequacy of food provided. Where an alternative to the meal has been provided this should be made clear. If any service user needs a special diet or assistance with eating, this needs to be made be clear in their personal records with a link to the record of food provision. Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 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 and 21 Service user plans provided detailed information about service users care needs and the way they preferred to be assisted. Discussions showed staff were familiar with this information and in meeting their needs treated service users with respect and dignity. There is a good approach to the assessment of service users communication skills/needs, but this needs to be linked to staff training to ensure the right support can be provided. Consideration must be given to ensuring staff have the skills needed to communicate in service users preferred mode, and it is strongly recommended consideration is given to providing total communication training for all staff. Staff reported good working relationships with members of the health care teams, which enabled them to better understand and promote service users health care needs. Work on health action plans was progressing. This now needs to be completed for every service user. This service provides care for service users over a wide age range, and staff are sensitive to the needs of older people. In planning staff training consideration should be given to the future care needs of older service users, with a focus on the normal ageing process and associated needs as well as specific difficulties which may be faced, for example dementia. . Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 16 EVIDENCE: Discussion with staff and service users and the service users plans seen, clearly identified individual needs and preferences, and showed support and encouragement is provided to each service user, to meet their personal care needs in a way which promotes independence with respect for individual dignity and choice. Communication needs and skills are assessed, one service user has the assistance of a speech therapist and another uses Makaton, however no staff have yet been trained in this technique. One service user described how her key worker was helping her put together her health action plan. Staff explained that these plans had not yet been completed for other service users but that this was proceeding. Staff said they valued the advice and guidance available from the primary healthcare teams and associated specialists, to help them make sure service users health needs are fully understood, and responded to appropriately. Staff had undertaken specialist dementia training in respect of the needs of one service user and reported that this had enabled them to offer personalised care more specifically related to her needs. However as yet there had been no training in the normal ageing process. This gap needs to be addressed. Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 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 and 23 A satisfactory complaints procedure is in place at the home, and service users are encouraged and enabled to express their views and opinions. No complaints had been recorded since the previous inspection. There was evidence that a concern raised was responded to with an appropriate outcome, however this had not been recorded and responded to as a complaint. A requirement from the previous inspection had not yet been met, to submit to the Commission a copy of the procedures for responding to suspicion or evidence of abuse, together with the organisations policy on physical intervention. Staff did demonstrate an awareness of the issues relating to abuse, but the need for further staff training to ensure the protection of service users, identified at the previous inspection, has not yet been met. There is a need for a more rigorous approach to ensuring the protection of vulnerable adults. EVIDENCE: A satisfactory complaints procedure has been produced and is included in the information provided to service users. A record of complaints is maintained, although none have been received at the home recently. Staff reported an occasion when a service user raised a concern, but although this had been investigated and acted upon it had not been recorded as a complaint. This is being taken up separately with the providers to ensure the correct procedures are followed and appropriate action taken. Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 18 Staff were able to demonstrate an understanding of the issues relating to abuse, but the need for training for all staff on the Protection of Vulnerable Adults (POVA) identified at the last inspection has yet to be acted upon. A copy of the procedures for responding to suspicion or evidence of abuse, together with the organisations policy on physical intervention was requested following the previous inspection but has not yet been submitted to the Commission. Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 19 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): 27 Attention needs to be given to improving washing facilities for this service, which currently do not fully meet the needs of these service users. EVIDENCE: The communal areas of the home are nicely decorated and comfortably furnished. There is a pleasant lounge/dining room, for the use of service users. The home is clean and free from offensive odours 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. The single bathroom does not provide for sufficient washing facilities for the household, especially for service users with particular hygiene needs. Action is planned in response to the requirement from the previous inspection, for wash hand basins to be installed in each service users bedroom. This has not yet been scheduled and the requirement therefore still stands. However, in view of the needs and age of current service users, it is strongly recommended further consideration be given to whether additional shower facilities can be provided. . Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 20 Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 21 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 and 35 The home’s new team of staff is now stabilising and beginning to work effectively together for the benefit of service users. Although there is still some reliance on agency staff pending the last vacancy being filled, 3 regular agency staff are now used who are familiar with the service and service users so improving continuity and confidence. The training programme available to staff is providing them with the basic competencies necessary for them to be effective in their work. A number of staff have now completed their induction training, they are aware of their own training needs and keen to progress to the next training level. Staff spoken to were very clear about their roles and responsibilities. Service users in this home have complex and varied needs. While staff showed a good understanding of these, a full programme of training is needed which will ensure staff have all the knowledge and skills they need to support these service users appropriately, including where needed, specialist communication skills. Staff reported that they receive regular supervision and are given appropriate support. EVIDENCE: Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 22 The rotas indicate that appropriate staffing levels are maintained to provide for the identified needs of service users. Although there is still the need to employ some agency staff, this is now confined to three known staff familiar with the service and service users, and able to contribute to service continuity. A training programme is in place at the home, and staff have undertaken induction training. Some are now ready to progress to the full training programme of National Vocational Qualifications (NVQ’s) linked with the Learning Disability Advisory Forum (LDAF). This will need to be designed specifically to address all the specialist needs of service users in this home. For example, one service user communicates using Makaton, but no staff yet have training in this method of communication. Furthermore it is recommended that the benefits of Total Communication training for all staff also be considered for this setting. Some specialist training is planned or has already been provided, in person centred planning, dementia, managing challenging behaviour and physical intervention. This group includes some older service users, so staff training must include an understanding of the normal ageing process and action to meet associated needs. Staff supervision was not inspected but staff reported that sessions are organised on a monthly basis, and that they found these supportive. Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 23 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, 40 and 43 There is currently no registered manager. While the available evidence indicates that the home is well run on a day to day basis by a respected acting manager, the service has been without a registered manager able to take full responsibility for the running of the home, for more than a year, and this must be resolved without further delay. There was no evidence of a full quality assurance procedure in place, and this now needs to be addressed. One referral has been received indicating staff are now familiar with the procedures for notifying the Commission about events affecting service users’ well-being. However, not all expected policies and procedures were in place or up to date and it was unclear if staff had read or were familiar with those available. The Commission had not received a monthly report on the conduct of the care home since August 2005, on behalf of the Responsible Individual. EVIDENCE: Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 24 Records seen were well maintained with evidence of good progress towards a person centred approach. Staff were well motivated and reported good support and supervision from the acting manager, while service users were content and at ease with the staff group, indicating a well run service. However it is essential a registered manager is in charge of the service to ensure compliance with legal requirements. The home’s policies and procedures were examined. The manual was not clear or easy to follow, and either there were no documents evident for the following, or those available were either out of date or not relevant to this service: Security Risk reporting procedures Personal safety at work Equal opportunities and non discriminatory practice Acceptance of gifts and legacies Dealing with violence and aggression Training and development While there was some evidence from staff signatures that some had seen available documents there was no systematic, dated signature process to monitor whether current staff knew and understood required policies and procedures. No evidence was seen of a full quality assurance procedure, action plan, inclusion plan or service plan for 2005/6 Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score X x X 2 X X x LIFESTYLES Standard No Score 11 x 12 X 13 X 14 x 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score x 2 x x 2 x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bromsgrove Road, 5 Score 2 3 x 2 Standard No 37 38 39 40 41 42 43 Score 2 X 1 2 x x 2 DS0000064301.V271432.R01.S.doc Version 5.0 Page 26 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 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 This was not completed by the date required for action and is repeated for this inspection 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 House rules must be revised to clearly specify the rights and responsibilities of group living in this home, and how these are to be met. The service user guide and the service user plan must be clear about individual contributions to housekeeping tasks. Training must be provided for all staff to enable them to meet all service users identified special needs, specifically, to ensure staff are on duty at all times who are able to communicate competently with service users DS0000064301.V271432.R01.S.doc Timescale for action 28/02/06 2. YA5 15 28/02/06 3. YA16 16 28/02/06 6. YA18 18 31/03/06 Bromsgrove Road, 5 Version 5.0 Page 27 using their preferred method 7. YA23 13 Training must be provided for staff on all aspects of abuse and the protection of vulnerable adults The timescale for action has not been reached and this requirement is therefore repeated A wash hand basin must be provided in each bedroom The timescale for action has not been reached and this requirement is therefore repeated All staff must be provided 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 The staff training programme must be designed to cover all identified special needs for the service users living in this home A manager must be appointed at the home and an application for registration submitted to the Commission without further delay The timescale for action has not been reached and this requirement is therefore repeated A full system of quality assurance and quality monitoring must be established for this service Arrangements must be made to ensure the home’s policies and procedures are appropriate to the setting, are complete and up to date, comply with current legislation covering the topics set out in Appendix 3 of the National Minimum Standards, and that staff understand and carry them DS0000064301.V271432.R01.S.doc 31/12/05 5. YA25 23 31/03/06 6. YA32 18 31/03/06 7. YA35 18 31/03/06 8. YA37 8 31/12/05 9. YA39 24 31/03/06 10. YA40 12 31/01/06 Bromsgrove Road, 5 Version 5.0 Page 28 6. YA43 26 out effectively so as to make proper provision for the health and welfare of service users. The person carrying out the monthly visit must prepare a written report on the conduct of the care home, and a copy must be submitted to the Commission This was not completed by the date required for action and is repeated for this inspection 31/01/06 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. Health Action Plans should be introduced for all service users In view of the needs and age of current service users, it is strongly recommended that consideration be given to the provision of shower facilities in addition to the sole bathroom. The staffing arrangements at the home should ensure that the use of agency staff is limited. 2. 4. YA19 YA25 5. YA33 Bromsgrove Road, 5 DS0000064301.V271432.R01.S.doc Version 5.0 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.V271432.R01.S.doc Version 5.0 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. 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