Inspection on 10/08/05 for 225-227 Coleshill Road

This inspection was carried out on 10th August 2005.

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

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

Other inspections for this house

225-227 Coleshill Road 09/06/09

225-227 Coleshill Road 14/06/07

225-227 Coleshill Road 07/09/06

225-227 Coleshill Road 07/02/06

225-227 Coleshill Road 20/01/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Coleshill Road, 227 227 Coleshill Road Hodge Hill Birmingham B36 8AE Lead Inspector Donna Ahern Announced 16 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Coleshill Road, 227 Address 227 Coleshill Road Hodge Hill Birmingham B36 8AE 0121 776 6844 0121 776 6843 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Elizabeth Fitzroy Support Mark Russell (Temporary Acting Manager) Care Home 6 Category(ies) of Younger Adults, Learning Disability [6], Physical registration, with number Disability [6] of places Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 23 February 2005 Brief Description of the Service: Elizabeth Fitzroy Support owns 227 Coleshill Road. The home provides care and accommodation to six adults who have learning disabilities and physical disabilities. The home is registered separately to 225 Coleshill Road although both homes are in the same development. Accommodation is provided in two self-contained flats and each service user has their own bedroom. In each flat there are three service users who share an open plan lounge, dining area and kitchen. A laundry room is provided in each flat, as is a bathroom with assisted bathing facilities and a separate toilet. A lift provides access to the first floor. The office and staff sleep-in room is located on the second floor. There is a garden at the side of the property, which can be accessed from the dining room door in the ground floor flat. Parking is provided to the side of the property. The home offers access to local amenities and local bus routes and transport links. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over one long day. The inspector met and spoke to all the residents. A partial inspection of the physical standards was undertaken. Residents care plans and risk assessments were inspected. Staff records were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the acting manager and four care staff. What the service does well: What has improved since the last inspection? The home had introduced a system for making sure that risk assessments are kept up to date. New medication procedures had been put in place to inform staff of the required practice for the management of recording medication on the record chart and the safe storage and administration of prescribed creams. So that residents are protected by safe procedures. New procedures had been introduced regarding good practice for the handling of resident’s money so that the provider can demonstrate that residents finances are well handled and protected from potential financial abuse. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 6 What they could do better: The provider was in the process of having residents needs reassessed and making sure that residents receive the right support. Staffing levels must be increased. The home must improve the care plans that they have on residents. These tell the staff how to support each resident. They must be clear about what help and support each residents needs and what the staff must do to help the resident. These must be kept up to date. Some of the risk assessments required more information so that they are really clear about what the risk is and the support required from staff. It was really positive that the acting manager was keen with the support from the staff team to develop the complaints procedure so that they can demonstrate that all residents are listened to and any concerns are recorded and dealt with. Progress will be monitored at the next inspection. Staff must have training in adult protection, person centred planning, epilepsy and anti discriminatory practice so that they have the up to date skills and knowledge to support residents and meet their needs. The kitchens in both flats required replacement. Cupboards are worn and damaged and some of the tiles are cracked. The current facilities could pose a health hazard for residents. The garden had been partly developed there was a decking area that leads down to a grass area which was difficult for the residents who use a wheelchair to access. It is strongly advised that the garden is developed in accordance with the views and wishes of the residents so that they can fully enjoy and access all the areas of their home. It was recommended that the provider looks at the systems in place for the recording of when a resident has an accident. It was recommended that entries are made into a binded accident book, which will prevent recordings from being misplaced and ensure that only the information required is recorded. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 Information was available about the home and had been produced in a suitable format for residents; some minor updating was required so that the information was current. EVIDENCE: The statement of Purpose and Service user guide required review and some updating to reflect changes in the service. The service user guide had been produced in a format that was more accessible to the people that live at 227 Coleshill Road. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 9 Further development of residents care plans was required so that an up to date plan of care is in place so that resident’s needs, aspirations and goals are clearly documented and monitored. Some further development of risk assessments was required so that the home can evidence that the risk residents face are well managed. EVIDENCE: Two care plans were assessed. There was a care plan structure in place and a lot of information was on file. The care plans required further development and a review of the structure and layout. Information and guidance added to the care plan must be dated and signed. The care plan must be kept under review with evidence that the individual plan is reviewed at least every six months. A number of risk assessments were on file for each resident and there was evidence that these had been reviewed. Some of the risk assessments required further development so that they are clear and specific about what the risks are to the individual resident and the action required by staff to reduce the risk. For instance risk assessments regarding nighttime support must be specific about how night staff make their checks, are they audible checks from Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 11 outside a person bedroom door or do staff physically check on residents the reason for this must be clearly documented. PCP (person centred planning) had commenced however this was at different stages of progress for each of the files assessed. To promote the development of residents care plans and PCP’s staff must receive the required training. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16, 17 Residents have a meaningful lifestyle, engage in appropriate activities, maintain links with their relatives, and have the support to have a healthy balanced diet. EVIDENCE: Four of the residents attend a structured day centre and two residents are supported by the staff team to access suitable day time opportunities. One of the residents went through their weekly activity plan and explained the different college courses that they had done and the new courses that they hope to start in September, at a new college. They also talked about the different hobbies that they enjoy doing at home. At the time of the inspection Day Centres were closed for the summer break. Two residents had been out to Chelmsley Wood and in the evening two residents were going swimming. The home has its own vehicle and residents contribute towards the running costs based on their use of the transport. If there are no drivers on duty alternative transport options are used including ring and ride and taxies. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 13 Three of the residents had recently been on holiday two went to Blackpool and one went to Breen with a resident who lives at 225 Coleshill Road. There were plans in place for the other residents to go on holiday. The acting manager said that some of the residents prefer a couple of short breaks rather than a week’s break. Staff stated and records indicated that where appropriate residents are supported to maintain contact with their relatives. Care plans had details of relative and friend contact arrangements. The visitor’s policy was on display in the entrance hall, and indicated that visitors will be made welcome to the home. Staff spoken to demonstrated a good understanding of the individual needs of residents and how residents communicate their different needs. Residents on flat one were observed undertaking a number of household tasks including helping out with food preparation, taking rubbish out to the bins, taking the washing off the line and putting it in the tumble drier and making drinks and snacks. Two of the resident’s spoken to said that they are enabled and supported to take part in a range of household tasks. On flat two, residents are less actively involved in household tasks staff said that partly this is because of their needs. Staff said they would sometimes take part with prompt and support from staff or sometimes the level of in put involves the resident just observing staff undertaking the tasks and staff verbally interacting with them. Two of the residents spoken to said that they could access all areas of their flat and the garden. They confirmed that they have a key to their door and staff will knock their bedroom door before entering. Menus were on display and indicated that a balanced and nutritional diet is offered to residents. Adequate food stocks were available in the home and food was stored and labelled with purchased and opening dates as required. Mealtime guidelines had been implemented for one resident as required at the previous inspection. These required some minor amendments so that the guidelines accurately reflect their needs and the supported required by staff. One residents weight was being monitored however, records of their weight was infrequent and the acting manager said the scales the home have are not accurate. The home must explore other options for monitoring the residents weight or provide scales that are adequate. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Residents receive a good level of support with their personal care and healthcare needs. Some improvements to the recording of residents’ healthcare was required so that there is documented evidence that their health care needs have been met. EVIDENCE: Residents were well dressed and there was good attention to people’s personal care. The care plans required some further development regarding how to support residents with their personal care needs. Manual handling assessments were in the process of being completed. Risk assessments were in place for residents who require staff support to transfer from a wheelchair to the bath. Both flats had well equipped bathrooms and the service of equipment had been undertaken as required. There was a core team of staff who knew residents needs well and there was a keywoker system in place. Residents care plans had “OK Health Checks” which are a health action plan format. These required further updating and development so that the format is fully used and the action plan section completed and evidence that resident’s health care needs are fully monitored. Details of outcomes of appointments were documented. One resident bed requirements must be reviewed, in order to alleviate breathing difficulties pillows are placed under the mattress. It was advised that Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 15 an appointment was made with the relevant professionals so that their needs could be fully assessed. CSCI must be informed of the outcome and any recommendations such as providing the relevant support equipment. The storage and administration of medication was generally satisfactory. The protocol/ guidelines in place for the management of one residents epilepsy required signing by the G.P and or consultant. Training for staff in epilepsy was required this must include an overview of epilepsy and training specific to the management of one person’s epilepsy. The risk assessment for one resident with epilepsy required some additional information including the required supervision during and after a seizure. The G.P or consultant must sign the epilepsy guidelines. The operations manger following consultation with CSCI pharmacy inspector had implemented procedures for the storage of “prescribed creams” and “writing on Medication Record Charts”. The Organisation has trained a staff member who is approved to train staff to the required accredited level in the “safe administration of medication”. It was agreed that this would be discussed with the CSCI pharmacy inspector for approval. The acting manager agreed to continue to review the location of the medication cabinet. Whilst accepting the limitations and potential problems with its current location in the laundry area there were limited alternatives. The temperature of the cupboard was being monitored so that it does not go above 25 degrees. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The complaints procedure was in the process of being made available in a format more suitable for residents. The adult protection policy was comprehensive. Staff training must be provided in adult protection matters so that residents are supported by an informed staff team who can safeguard residents from abuse. EVIDENCE: Only two of the six residents would be able to verbally raise a concern or a complaint all other residents are reliant on the staff team to promote and protect their well being. There was a complaint policy and procedure in place. The provider had received no complaints. The acting manager had just received a revised procedure, which included an audio and videotape. Staff training is to be provided on the new package. The acting manager demonstrated a real commitment to promoting staff awareness of really listening to residents views and developing an open culture and supporting residents who are not able to verbally raise their concerns. The organisations Adult Protection Procedure was assessed and the appendix (iii) had been completed so that it contained a flow chart and boxes for relevant contact details in the event of a protection matter being identified in the home. There was a copy of the Birmingham Multi-agency Guidelines available to compliment the organisations own policy and procedure. The operations manager stated that Adult Protection training would be implemented into the induction training. The organisation will need to explore how up dates and refresher training will be provided for all staff. Staff spoken to demonstrated an understanding of what to do in the event of an Adult Protection matter arising in the home. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 17 The acting manager had implemented the organisations new finance procedures. The finance arrangements in place for two residents were examined and were found to be well organised. There was a financial risk assessments which clearly set at the arrangements in place and the support the resident required from staff to manage their finances. Cash sheets were in place for each month and cheque sheets and bank statements. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 Residents live in a homely, comfortable and safe environment. EVIDENCE: Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 19 227 Coleshill Road consists of two, three bedded flats. The home was a purpose built property and therefore meets all the required standards. The two flats were generally well maintained, accessible and safe and free from offensive odours. They meet the current needs of residents. A previously raised concern was access to the laundry for residents; the inspector was informed that the layout of the laundry was under review. The kitchens in both flats required replacement cupboards are worn and damaged and some of the tiles are cracked. The current facilities could pose a health hazard for residents. CSCI must be informed of timescales for this work to be actioned. The garden had been partly developed there was a decking area that leads down to a grass area which was difficult for the residents who use a wheelchair to access. Residents have put some plans together with the help from staff of how they would like the garden to be developed. Two of the residents said they enjoyed spending time in the garden. It is strongly advised that the garden is developed in accordance with the views and wishes of the residents so that they can fully enjoy and access all the areas of their home. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35, 36 Staffing levels must be reviewed so that the home has an effective staff team, in sufficient numbers to meet resident’s needs. Staff must receive regular supervision so that residents are supported by a well-supervised staff team. EVIDENCE: Staffing levels were three staff on duty at core times when all the residents are at home. This allows one staff in each flat and one staff member going between the two flats to support. The rota indicated that there was some flexibility with the rota and at time four staff are on duty to support evening activities. At night there is one person doing a waking night shift and one person on call on a sleeping in shift between the two registered homes 225 and 227. One week the person is based in 225 and the following week they are based in 227. The previous report required that a review of staffing levels must take place as two staff was required at core times on each flat. The Operations Manager stated that she was in the process of requesting reassessments of all residents with the relevant placing authorities, as part of the review process. CSCI must be informed of the outcome. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 21 There was a core team of staff who have worked at the home for a long time and more recent appointments have meant that the home has benefited from a good range of staff with varying experiences and both male and female support workers. Some staff were due to move on to positions for personal development reasons which will mean that the home will have some vacant positions. The acting manager said staff increasing their hours will cover some hours and the other vacant posts will be recruited to in the forthcoming months. Agency staff will cover any shortfalls. The acting manager said that regular agency staff are used and that they were in receipt of profiles, detailing their experience and CRB details. The staff training records were examined and indicated that mandatory training is provided to all staff. Some updates and refreshers were required and these were said to be in hand and are scheduled to take place over the forthcoming months, so that staff have the up to date knowledge and skills to support resident’s needs. Training was required on epilepsy, adult Protection, person centred planning disability equality training and anti-racism. Two staff files were examined and these contained the required information including application form, references, CRB check and proof of identity. Supervision records were assessed and indicated infrequent supervision over the last twelve. Regular supervision must be provided for all staff at least six per year with records kept. It was discussed with the acting manager how personal information that staff may share in supervision could be recorded and filed. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 42 Health and Safety matters were well managed. Staffing levels must be reviewed so that the well being of residents is fully promoted and protected. EVIDENCE: The registered manager resigned in October 2004. There have been temporary management arrangements in place. The assistant manager has acted up in the manager position for a protracted period. For several months he was the only manager. Since March 2005 a support worker had been acting assistant manager. A new manager had recently been appointed and it is anticipated that they will take up post in September 2005. An application to register the manager must be forwarded to CSCI. It was proposed by the organisation and CSCI have agreed that the manager will be the registered person for 225 and 227 Coleshill Road. Throughout the inspection process the acting manager presented as open, positive and inclusive. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 23 A number of required records were examined including risk assessments for the environment, COSHH, fire records, and water checks and were all found to be in good order. Staffing levels required review as raised in previous reports and in section 33 of this report. Risk assessments regarding the care and support of residents required some further development as raised under standard 9 of the report. The accident procedure had been revised since the previous inspection to incorporate the date protection requirements. The home was still using loose sheets for the recording of any accidents or incidents. The recording sheet is lengthy and the use of loose sheets is problematic as there is the potential for information to become misplaced. It was strongly advised that this system is revised and consideration given to the using of a bounded accident book with numbered pages. Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score x x 2 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Coleshill Road, 227 Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 25 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 1 Regulation 4 (1) (c ) schedule 117 (2) schedule 4 15 (1) (2) Requirement Some updating of the Statement of Purpose and Service User Guide was required. Care plans required some further development. Timescale for action 31st October 2005 30th November 2005 31st October 2005 30th September 2005 & ongoing 30th September 2005 & ongoing 16 th September 2005. 30 th september 2005 16th September 2005. 30th Page 26 2. 3. 4. 6 9 17 13 (4) abc Risk assessments required further development. 12 (1) (a) Residents weight must be monitored monthly and a record of these must be maintained in their personal records. Health Action Plans required some further development. The protocol/Guidelines regarding management of epilepsy for one resident required signing by a medical practitioner. An assessment of one residents sleeping needs was required. The risk assessment in place for the management of epilepsy required some development. The kitchen cupboards required 5. 19 12 (1)a 13 (1) (b) 12 (1) (a)13 (1) (b) 12 (1) (a) 23 (2) (n) 12 (1) (2) 23 (2) ab 6. 20 7. 8. 9. 18 20 24 Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 10. 33 11. 35 12. 36 replacement. The layout of the laundry required review. The registered person must inform CSCI of the proposed timescales for this work. 18 (1) (a) The registered person must inform CSCI of the outcome of the reassessment of residents needs and the review of staffing levels. CSCI must be informed of the staffing assignment for the home and how the new management structure will work. 18 (1) (c ) All staff must receive training in Adult Protection, Epilepsy, Person Centred Planning, Disability Equality training and Race Equality. 18 (2) All staff must have regular, recorded supervision meetings at least six times a year. September 2005. 31st October 2005. 31st December 2005 30th September 7 ongoing 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 24 Good Practice Recommendations It is strongly advised that the garden is developed in accordance with the views and wishes of the residents so that they can fully enjoy and access all the areas of their home. It was strongly advised that the accident recording system is revised and consideration given to the use of a bounded accident book with numbered pages. 2. 42 Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coleshill Road, 227 E54 S16729 Coleshill Road 227 V239151 160805 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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