Inspection on 04/08/05 for 58 Featherstone Road

This inspection was carried out on 4th 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

58 Featherstone Road 11/07/07

58 Featherstone Road 18/07/06

58 Featherstone Road 14/02/06

58 Featherstone Road 09/03/05

58 Featherstone Road 07/10/04

58 Featherstone Road 12/03/04

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 Featherstone Road 58 Featherstone Road Kings Heath Birmingham B14 6BE Lead Inspector Kerry Coulter Announced 4 August 2005 th 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. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Featherstone Road Address 58 Featherstone Road, kings Heath, Birmingham B14 6BE 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) 0121 444 6600 0121 443 4968 Sense West Craig Merrick Care Home 4 Category(ies) of Learning Disability - Sensory Impairment (4) registration, with number of places Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 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 9th March 2005 Brief Description of the Service: Featherstone Road is a substantial detached home providing spacious accommodation and a specialist service for adults with sensory impairment and learning disabilities. The home is registered for four service users. The fifth bedroom is used by staff as two rooms, as a sleep-in room and an office. The home is in a pleasant residential area of Kings Heath close to shops, churches, leisure facilities and Kings Heath Park. The home provides five single bedrooms, four on the first floor and one on the ground floor, and a small office / staff sleeping-in room. Two bedrooms have ensuite facilities and all are individualised to reflect service users personalities. There is a large bathroom upstairs and a toilet downstairs. The lounge is a good size and is comfortable and homely. The house has a large modern fitted kitchen and a comfortable dining room. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 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 day. Conversations with service users were limited due to their complex needs and limited verbal communication abilities. However, the inspector was able to spend time with the people who live at the home observing care practices, interactions and support from staff. A tour of the building was made. Care plans and risk assessments were inspected. Staff training and recruitment procedures were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk with the Manager, Practice Development Worker and informally to support workers. Information has also been obtained from the pre inspection questionnaire completed by the Manager prior to the inspection. CSCI comment cards had not been received from relatives, care managers and health and social care professionals at the time of writing this report. What the service does well: What has improved since the last inspection? The home is working hard on improving care plans and risk assessments. These tell the staff how best to support people and they have lots of information in them. The home had worked hard on making information easier to find which is really important especially when new staff come to work at the home. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 6 Health action plans have been introduced. This is a plan that records everything an individual needs to stay healthy. Some internal redecoration and refurbishment has taken place making the environment a more pleasant place to live. The home has recruited an additional driver, this means that service users are offered increased opportunities to access the community. 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. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 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 standard(s) 1 and 2 The Statement of Purpose and Service User Guide provide most of the information needed to make an informed choice about services provided, and this is reinforced by assessment and admission procedures. EVIDENCE: The home has a statement of purpose and a service users guide. Some minor amendments are required to the documents as identified at previous inspections. The documents must be updated to include current management details. The service users guide must include any additional charges, to include transport charges. It is positive that the service user guide is specific to each individual and includes photographs. Consideration should also be given to the use of video or audio as suitable to individual need. The home currently has a vacancy. The Manager demonstrated that he was aware of the requirement that new service users are only admitted on the basis of a full assessment undertaken by people competent to do so. He also stated that the needs of current service users would be taken into account before any new admissions to ensure service user compatibility. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 The care planning system in place required minor improvement to provide staff with the information they need to satisfactorily meet service users needs. People are supported to take responsible risks, but some work needs to be done on the ways in which risks are assessed and how this information is presented. EVIDENCE: Discussions took place with the Practice Development Worker (PDW) regarding the system for care planning. The PDW said that development of the care plans was underway, with two having been completed and one still in progress. Two care plans were sampled. In general the care plans sampled were up to date, however the behaviour management guidelines had passed their date for review. Evidence was available that other professionals are involved in the care of people who live at the home, for example the Speech and Language Therapist has completed assessments for eating and drinking. Care plans generally contained detailed information, however for one individual further information on their cultural needs and how these should be met were required. Plans contained some information about night time support needs but these needed expanding. If checks are to be made by night staff then it Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 10 must be clearly documented how these checks are to take place for instance visual or physical check, from outside or inside the bedroom. Some attention is required to the terminology used by staff when completing daily records, on some occasions phrases such as ‘played up again’ and ‘was grumpy today’ were recorded. The Manager must ensure that staff are respectful of service users when completing records. Members of staff actively encourage each service user to take responsibility for as many things are they are able, within their individual capabilities. They seek to promote choice wherever possible, and respect the choices people make. Individuals’ communication difficulties place some restrictions on how this is put into practice. Where possible, attempts are made to overcome this, for example, through the use of objects of reference. Risk assessments sampled were up to date but the level of risk needed to be made clearer within the assessments sampled. There was some cross referencing of care plans and risk assessments but this needs to be further developed. Each risk assessment should be directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other. One of the outcomes for completing risk assessments and care plans should be that the finished article is a simple and effective working document, in which essential information can be easily found. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 11 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, 15, 16 and 17 Recording practice needs to improve to evidence that a range of activities is offered and meet the needs of service users. Staff offer appropriate support to enable individuals to maintain contact with relatives. Service users enjoy a healthy and nutritious diet. EVIDENCE: Previous inspections reports have recorded concerns about the level of activities on offer. The needs of service users and lack of drivers had a detrimental effect on the opportunities on offer. The opportunities on offer have now improved, this is in part due to one service user moving out of the home but also due to the recruitment of an additional driver. The care plans contained a “Schedule of activity”. Activities on offer include music, daily living skills, dance, art and massage. On the day of the inspection service users were involved in an in house art session. Later on in the day one service user was supported by staff to go shopping. Whilst the activities are varied sampling of records indicate that sometimes the planned activity does Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 12 not take place. Some recordings stated “went out” there was no details of where too, or the persons response to the activity. The Manager must ensure that staff record why the planned activity did not occur as this is not being consistently recorded and makes it difficult to assess if service user needs are being met. As part of the homes on going development work around leisure and activities consideration must be given to how the home can evidence that the planning of the schedules reflects the choice of the service user. The home has a visitor’s policy and actively encourages visits from family and friends. There was evidence that relatives also have contact by the telephone and letters /cards. Staff said that one service user had also been on holiday to Barbados this year in an attempt to establish contact with relatives who live there. It is an area of good practice that SENSE employs a Family Liaison Officer; she had been involved with relatives in the process of the new admission to the home. Additionally, a family weekend is also arranged at a local hotel where relatives can meet with SENSE representatives and other relatives. The menus inspected showed that the food was varied, wholesome and nutritious. Food stocks were satisfactory. People who live at the home assist in the shopping for food. The food actually eaten is recorded in detail in the daily records. A lunchtime meal was observed. Staff sat at the table with service users and support was given in line with individual care plans. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 13 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) 19 and 20 The health needs of service users are well met. The systems for the administration of medication require improvement to ensure service users medication needs are met. EVIDENCE: The previous inspection report from March 2005 identified shortfalls with regard to health needs. At this inspection there was evidence of service users receiving regular health checks and monitoring, and records are maintained. Records show that referrals are made to healthcare professionals as and when required. A new format for Health Action Planning has been introduced recently. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. Good work has been done in seeking to identify and systematically record individuals’ health needs. This should now be built on so that the document moves from being a statement of need to a planning and monitoring tool. The system for the administration of medication is generally satisfactory. Medicines were seen to be stored appropriately in a secure location. A random audit of stocks held revealed no discrepancies, and there were no gaps on the administration record. A tube of topical cream were observed to be open, but Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 14 no date of opening was recoded on the tube. This must be done and the cream discarded within 28 days of opening. Some service users are prescribed medication to be taken on an ‘as required’ basis. The home has written protocols on the administration of these medications but these required review. In addition, they should be further developed. For example, one service user has paracetamol for pain/distress. As this individual has limited verbal communication the protocol needs to guide staff as to the signs of the individual being in pain/distress. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 15 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 and 23 The home does not have a satisfactory complaints procedure. Adult protection procedures impact on the homes ability to show that service users are being protected from abuse and that their welfare is being promoted. EVIDENCE: The homes complaint procedure includes information on the role of the CSCI in investigating complaints and is available in a picture format and CD Rom. Some of the service users due to their complex needs are not able to make a complaint and are reliant on staff, relatives or an advocate to act on their behalf. CSCI had investigated no complaints from service users or any other source in respect of this home in the past twelve months. It was queried at this inspection where complaints would be recorded. A folder was produced that contained a variety of forms but none relating directly to complaints. A specific log is required that leads staff to seeking the required information from a complainant, to include date, method of complaint, name of complainant if known, detail of complaint, action taken to investigate and outcome and response to complainant. The home had a written prevention of abuse policy that is robust. As required previously the contact details in the event of an issue arising had been completed on the flow chart and it was displayed in a conspicuous place for staff reference. The manager stated that Sense completes a Criminal Record Bureau check before staff start work in the home. However, the Manager was unable to locate the records to evidence that these checks had been done. These must be available in the home for inspection, this is further detailed in Standard 34. Staff receive adult protection training but several staff are now due for refresher training. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 16 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, 26, 27, 28, 29 and 30 Some fixtures and fittings require replacement to ensure the home presents as a homely and comfortable environment for the people who live there. Standards of hygiene need to improve to ensure there are effective infection control measures in place. EVIDENCE: Featherstone Road is a domestic style house that is in keeping with houses in the locality. At the previous inspection the CSCI were informed that refurbishment of the bathroom was scheduled. This has now been completed and the layout is much improved. The lounge has been redecorated and new chairs purchased for the dining room since the last inspection. The Manager stated that an en-suite bathroom is next on the schedule for refurbishment, the corner bath is to be replaced as it is currently positioned under a sloping roof. Bedrooms sampled were observed to be personalised according to individual needs and preferences. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 17 Some maintenance issues were observed to require attention. Repairs were required to some fire doors. The lounge carpet was badly stained. The Manager stated that the carpet had been cleaned recently but that it had not proved possible to remove the stains. The carpet will therefore require replacement. The floor covering in the downstairs toilet requires resealing where it is coming away from the wall. The laundry room décor was observed to require attention. The walls were quite stained, it should be investigated if there is adequate ventilation in this room. Several extractor fans were observed to require cleaning as they were clogged with dust and dirt. Suitable adaptations have been made to the home to ensure it meets the needs of individuals with a sensory impairment. This includes objects of reference attached to doors so individuals know where they are in the home and bedrooms have appropriate systems installed to alert individuals to someone entering their room. It was previously required that a washing machine with a sluice cycle is installed, the Manager stated that a capital bid had been made for the money to purchase a new machine. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 18 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) 33, 34, 35 and 36 Staff have a good understanding of the service users support needs. Refresher training must be arranged for staff to ensure they have the appropriate knowledge and skills to support service users. Staff records require improvement to evidence that service users are being safeguarded by satisfactory recruitment procedures. EVIDENCE: Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 19 Rotas indicated, that typically two care workers staff the home during the day, and at night there is one waking night staff and one sleep in member of staff on call. A practice development worker and an agency member of staff who does driving duties are also available for two days per week. Since the last inspection a new Deputy Manager has commenced work in the home. The Manager is soon to transfer to another of Sense’s homes and the Deputy Manager will be taking on the position of Acting Manager. Apart from the forthcoming manager vacancy the home does not have any staff vacancies. Given that there are only three service users living at the home the current staffing numbers are adequate to meet individual need. However the home was not able to show that the Manager/ Deputy Manager hours worked are sufficient as the rota did not always record their hours. Staff recruitment records were sampled. For one member of staff their file contained no proof of identity and the Manager was unable to find the records to evidence that Criminal Record Bureau checks had been undertaken for staff. The Manager stated that a Personnel Officer from Sense had completed an audit of staff files the week before the inspection and already identified a list of outstanding information to be included in some files. The pre inspection questionnaire completed by the Manager states that 80 of staff have completed an NVQ thereby exceeding the required standard of 50 . Some refresher training is required for some staff to include physical intervention, food hygiene, first aid, adult protection and medication. The Manager stated that it was hoped staff would receive refresher training soon as Sense have recently appointed a second training co-ordinator to ensure staff receive the training they need. Some service users have a history of epilepsy, this will need to be added to the training schedule as there was no record of epilepsy training for staff. Discussions with staff and sampling of supervision records indicate that staff receive satisfactory supervision. Staff spoken with were positive about the support received from the Manager and Deputy Manager. Some staff raised issues about the home’s rota, this was brought to the attention of the Manager during the inspection. Staff spoken with demonstrated a good knowledge of the needs of service users at the home. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 20 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) 39 and 42 The health, safety and welfare of the service user had not been adequately promoted and protected. EVIDENCE: Systems are in place to assure quality. This includes monthly visits to the home by the General Manager who completes a report and forwards a copy to the CSCI. Audits are carried out periodically to include the staff files by personnel. Additionally, part of the role of the Practice Development Worker is to complete quality assurance audits, this includes the level of activities on offer. Some concerns regarding the safety of the building were identified and raised concern regarding the homes compliance with relevant Health and Safety legislation. Certificates to evidence the safety of gas and electrical portable appliances were not available, a requirement was made for a copy of these to be forwarded to the CSCI. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 21 Two fire doors on the ground floor were found to have part of their smoke seals missing. The majority of staff had not had fire training since June 2003. Previous reports have required that staff receive fire training at least six monthly. The Manager stated that formal fire training had been arranged for August, September and November. The delay in training was of concern and a letter regarding this has been sent to Sense. In response, the General Manager has assured the CSCI that additional fire training for staff has been arranged. Records evidenced that the fire alarms have been serviced on a regular basis. Staff also undertake regular checks of the water temperatures to ensure water is safe and service users are not at risk of being scalded. Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 22 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 x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 2 3 3 2 Standard No 11 12 13 14 15 16 17 x 2 3 x 4 3 3 Standard No 31 32 33 34 35 36 Score x x 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Featherstone Road Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 1 x E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 23 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 17 (2) schedule 4 (1) (2)4 (1) (c )Schedule 1 Requirement Timescale for action 30/10/05 2. 6 5 3. 9 13(4) 4. 12 16(2) Additions are required to the Service Users Guide and Statement of Purpose:The Service Users Guide required current manager details. The Service Users Guide and Statement of Purpose must include any additional charges. Outstanding from 7/12/04. Care plans require further detail 30/9/05 on the night time support and cultural needs of individuals. Behaviour management guidelines require review. Risk assessments must be 30/9/05 undertaken in respect of the support required at night by service users. Risk Assessments must cross reference to service users care plans. Outstanding requirement from 7/12/04. The risk assessment must clearly record the level of risk. Daily records require 30/9/05 improvement to evidence that service users are offered a choice of activities and the reasons why planned activities do not take place. Consideration must be given to how the home can evidence that the planning of Version 1.40 Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Page 24 the activity schedules reflects the choice of the service user. 5. 20 13(2) Topical creams and ointments must be dated on opening and discarded after 28 days. As required protocols for medication require review and further development. A specific complaints log is required that leads staff in seeking the required information from a complainant, to include date, method of complaint, name of complainant if known, detail of complaint, action taken to investigate and outcome and response to complainant. Lounge carpet- stains must be removed or the carpet replaced, ensure laundry room is adequately ventilated and arrange for redecoration. Schedule of work to be sent to CSCI. Flooring in the downstairs toilet requires resealing where it is coming away from the wall and extractor fans require cleaning. A washing machine with a sluice cycle must be installed. Outstanding requirement from 7/12/04. Hours worked by the Manager and Deputy Manager must be recorded on the rota. The home must have the required staff records available in the home to include evidence of CRB checks. Ensure all staff have received refresher training to includeAdult protection Physical Intervention Food hygiene First aid Outstanding from 7/12/04 5/8/05 Immediate requiremen t 30/9/05 30/9/05 6. 7. 20 22 13(2) 22 8. 24 23(2) 30/9/05 9. 30 23(2) 30/9/05 10. 30 16(j) 30/10/05 11. 12. 33 34 18(1)(a) 7,9,19 schedule 2 and 4 18(1)(c ) 30/9/05 30/9/05 13. 35 Training plan required by 30/9/05 Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 25 14. 42 13(4) 23 13(4) 23 13(4) 15. 42 16. 42 Staff must also have received accredited medication and epilepsy training. All staff must receive fire training at least six monthly. Outstanding requirement from30/4/05 An audit of the smoke seals on fire doors is required and smoke seals to be replaced where required. Copies of up to date certificates for gas and electric portable appliances to be forwarded to the CSCI. 4/9/05 Immediate requiremen t 4/9/05 Immediate requiremen t 18/8/05 Immediate requiremen t RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 26 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 Featherstone Road E54 S16715 FeatherstoneRoad V237441 040805 Stage 4.doc Version 1.40 Page 27 - 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!