Inspection on 10/11/05 for Ferndale Crescent, 10

This inspection was carried out on 10th November 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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ferndale Crescent, 10 30/06/09

Ferndale Crescent, 10 03/07/08

Ferndale Crescent, 10 14/02/07

Ferndale Crescent, 10 04/05/05

Ferndale Crescent, 10 23/09/04

Ferndale Crescent, 10 26/04/04

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 Ferndale Crescent, 10 Moseley Birmingham West Midlands B12 0HF Lead Inspector Sarah Bennett Unannounced Inspection 10th November 2005 13:30 Ferndale Crescent, 10 DS0000016880.V269760.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 Ferndale Crescent, 10 DS0000016880.V269760.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. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ferndale Crescent, 10 Address Moseley Birmingham West Midlands B12 0HF 772 1885 766 6856 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) Trident Housing Association Ms Maria Bulloch Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 4th May 2005 Brief Description of the Service: 10 Ferndale Crescent is located in a residential area of Highgate on the outskirts of the city centre. Therefore the city centre is easily accessed by public transport. The home is registered to provide support to eight adults who have a physical and learning disability on a permanent basis. The home is owned and managed by Trident Housing Association. At the time of this inspection there were five residents living in the home. The home caters for adults of mixed gender. All bedrooms are single and have an en suite facility. There are six bedrooms on the ground floor and two on the first floor, which can be accessed by a chairlift if required. Three of the bedrooms have an overhead hoist. The communal areas comprise of an open plan lounge and dining room, kitchen and sensory room on the ground floor. The laundry is situated on the first floor. The home is staffed 24 hours a day and at night there is one waking night staff and one member of staff sleeping -in. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over five and a half hours. Residents, the manager and the staff on duty were spoken to. A partial tour of the premises took place. Care, staff and health and safety records were looked at. Mandy Warner (expert by experience) and her supporter from ‘Sandwell People First’ were there for part of the inspection. As a service user Mandy has an expert opinion on what it is like to receive services for people who have a learning disability. As part of the Inspection Team, Mandy’s comments are included throughout this report. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from May 2005. What the service does well: What has improved since the last inspection? One resident has had a new bed. Some work has been done to improve resident’s en suite facilities such as replacing tiles and toilet seats and repairing handrails. Staff have had training in food hygiene, manual handling and medication so that they can meet the needs of residents better. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 6 The manager has been registered by the CSCI. There is now a deputy manager working at the home also to support the manager. Residents risk assessments have been reviewed and updated so that all risks to residents have been assessed. Ways to minimise the risks are written down for staff to follow. More staff have been recruited to work at the home. Agency staff are employed at the home but these are people who work there regularly and know the residents well. Agency staff attend staff meetings so that they are part of the team and are aware of how to meet residents needs. What they could do better: Residents care plans should be person centred plans. They should include photographs and pictures if this will help individual residents to understand them better. Complaints and fire procedures that residents can understand should be displayed in the home. All residents should be offered the chance to go on holiday each year. Each resident must have a Health Action Plan so that they are supported to stay healthy and access appropriate healthcare services. Residents must be weighed regularly and a record of this kept so that staff can monitor any changes in their weight. Residents who are prescribed as required medication must have a protocol in place stating when the medication should be given. Maintenance work needs to be completed so that all residents have appropriate en suite facilities. Another use needs to be found for the sensory room so that it is used in a way that benefits the residents. The kitchen must be accessible to all residents so that they have a chance to develop their skills in independence. All staff recruitment records must be in place so that it is clear that the necessary checks are done on staff to make sure they are safe to work with the residents. Staff must have the appropriate training to meet all the needs of residents. All the recommendations from the Fire Officer must be put in place to ensure that fire safety arrangements are adequate. Staff must have training in fire safety. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 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. Ferndale Crescent, 10 DS0000016880.V269760.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 Ferndale Crescent, 10 DS0000016880.V269760.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): These standards were not assessed at this inspection. EVIDENCE: Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Staff have the information they need in residents care plans to know how to support them but these could be developed further so that they are person centred. Residents make decisions and are consulted about their lives in the home. Residents are supported to take risks within a risk assessment framework. EVIDENCE: All the residents had a care plan. The care plan contained information about how staff are to support the individual in all aspects of their lives. They were not accessible plans and were kept in the office. One resident told the Inspection Team that “Things like, I go to college and what my personal needs are” were written in their care plan. They said that they would like some pictures or photos put in their plan so that they can understand it better. Some work has been started on Person Centred Plans and these should be developed further. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 11 Staff were observed asking residents what they would like to do, where they would like to spend their time and what they would like to eat and drink. Residents records showed that residents are supported `to make decisions about their day-to-day lives. One resident told the Inspection Team that residents’ meetings take place every month. They said they talk about different things. Residents said that they are involved in interviewing for new staff. The manager said that Trident have recently employed a tenant participation assistant who has been to meet the residents and will set up formalised residents meetings in the New Year. Individual risk assessments are in place for residents. These were detailed and had recently been reviewed and updated with any changes. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Residents are supported to be part of the local community. Some further development is needed to ensure residents experience a meaningful lifestyle. Residents are supported to have appropriate family relationships. Residents are offered a healthy diet and enjoy their meals. EVIDENCE: Four of the residents go to daycentres during the week. One resident told the Inspection Team that they stay in on Monday and Tuesday and goes to college the rest of the week. A befriender from the Share scheme is to visit them soon. The resident hopes that they will be able to spend some time with them on Monday and Tuesday. Transport comes to pick the residents up to go to college or day centre. The residents also go out by taxi. A member of staff talked about the possibility of taking residents out on accessible public transport buses and said that they would explore this further. One resident told the Inspection Team, “ I watch TV most evenings, and we all choose what we want to do. Sometimes we go to the cinema and bingo.” One resident told the Inspection Team they would like to go to a football match to watch Birmingham City play. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 13 One resident spent most of the time in their bedroom and chose to have their evening meal there. Their records showed that they often spend time alone and sometimes refuse to go to the daycentre. The manager said that they have been concerned about this resident’s health and referrals have been made to relevant health professionals. One resident spent time colouring in and talking to staff and other residents. One resident went out for their evening meal supported by a member of staff. Residents who want to are supported to go to church on Sundays. Residents go to discos, pubs and restaurants. One resident said that they went on holiday with support to Nottingham for a week. Another resident has been to Wales with a member of staff and residents from another home. Two other residents said that they had not been on holiday but would like to go. The manager said that three residents have not been on holiday this year. A holiday was booked but unfortunately was cancelled due to staff not being available to support them. The manager said this was being discussed at the staff meeting the following day and residents were hoping to go on a long weekend break. Residents told the Inspection Team that their relatives visit them at the home. They said that they only see their friends at the daycentre. The manager said that one of the residents recently celebrated their 40th birthday with a party at the home. Their relatives and friends came to the party. The laundry is on the first floor and not accessible to the current residents. One resident told the Inspection Team that they would like the washing machine brought downstairs so that they could be supported to do their own laundry. The use of the current sensory room for this purpose should be considered. One resident told the Inspection Team that they choose what food they eat. They said, “we all have different choices.” “Staff write the list but we tell them what we want on the list.” “ I go shopping with the staff in a taxi” One resident said, “ the staff cook the dinner but sometimes I help to prepare the vegetables”. They said, “ I would prefer it if the work surfaces were lower down so I could help more in the kitchen”. The staff were preparing the dinner in the kitchen. The Inspection Team thought that at least one of the residents could have helped in the kitchen in some way. If the kitchen surfaces and sink were moved to a lower level then the residents would be able to be supported to do more chores in the kitchen. Residents said the surface had been lowered but it is still not low enough. Residents were observed going in and out of the kitchen during the evening. One of the residents chose to eat their meal in their bedroom. Staff brought their meal into their bedroom but the resident was not able to access it without assistance from the inspector. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 14 Records of food showed that residents are offered a varied diet with fresh fruit and vegetables. Ferndale Crescent, 10 DS0000016880.V269760.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, 20 Residents receive personal support in the way they prefer and require. Further development is needed to ensure resident’s health needs are fully met. Practices relating to the storage and administration of medication are generally satisfactory but improvements to written medication protocols must be introduced. EVIDENCE: Residents told the Inspection team that they can go to bed when they choose and get up when they want to. One resident said they were very tired after tea and were supported to get ready and go to bed about 7pm. Residents said, “Staff take me out shopping to choose what I want.” Residents care plans stated how staff are to support them with their personal care. Staff were observed changing residents clothes when needed. Manual handling risk assessments are in place for residents to ensure the safety of the resident and staff. Health professionals are involved in the care of residents where appropriate including psychologists, speech and language therapists, psychiatrist, community nurse, occupational therapist and dietician. Residents have regular check –ups at the dentist and optician. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 16 Residents weight charts had not been completed since March 2005. Residents must be weighed regularly as this can be an indicator of changes in their health. The manager said that the community nurse is working with the residents and staff in developing Health Action Plans for the residents. This is a personal plan about what a person who has a learning disability can do to stay healthy and access appropriate health services. These are being developed using pictures to make them easier to understand. A local pharmacist supplies the medication to the home using a blister pack system. Medication is stored in a locked cabinet. Staff had signed on residents medication administration records to say that they had given the medication to residents which indicated that medication is given as prescribed. One resident is prescribed as required (PRN) medication to be given when they become agitated. There was no protocol stating when this should be given. The manager said that the community nurse is working with the resident and developing the protocol. Separate storage is provided for Controlled Drugs (CD’s) and a register is kept to ensure these are given and stored appropriately. The register crossreferenced with the medication stored in the CD cabinet. Ferndale Crescent, 10 DS0000016880.V269760.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, 23 Arrangements to inform residents of how to make a complaint should be clearer to ensure that their views are listened to and acted on. Adequate arrangements are not in place to ensure that residents are protected from abuse, neglect and self-harm. EVIDENCE: The manager said there have been no complaints since the last inspection. Residents told the Inspection Team that if they were unhappy they would talk to staff. They said, “The staff are so good I don’t need to complain.” The Inspection Team noted that there were no easy to understand complaints procedures up anywhere in the home. Resident’s records included a complaints procedure produced using pictures. Records may not always be accessible to residents as they were kept in the office upstairs so it would be better if it was displayed somewhere downstairs. The complaints procedure included details of how to contact the CSCI. The manager said that training in adult protection remains outstanding. Residents told the Inspection Team that they have their own bank accounts and choose what they want to spend their money on. Where appropriate there are behaviour management guidelines in place for residents who at times display behaviour that can be challenging. These ensure that staff deal with the behaviour in a consistent way. Resident’s records included an inventory of residents belongings that had been regularly updated. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 The home is comfortable, generally clean and homely. Some further work is needed to ensure that it is accessible and meets the needs of all residents. EVIDENCE: One resident told the Inspection Team that they have a key to their bedroom and they lock it. They have a shower room attached to their bedroom. The ex by ex said: “This is good because they don’t have to share with everyone else”. The Inspection Team found that in one residents bedroom there was felt tip pen over their quilt cover and bedside table. Staff need to ensure that this residents bedding is changed regularly and there is always drawing paper provided, which the resident is encouraged to use. Resident’s bedrooms contained many personal possessions. Bedrooms were warm and residents had sufficiently thick duvets for the season. One resident said that they had recently bought some new bedding. At the last inspection a requirement was made for the shower in one resident’s en suite to drain away efficiently as there was an offensive odour in this room. This remains outstanding and the manager said a building surveyor has visited twice. An order has been placed with the maintenance department for this work to be done. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 19 The equipment in the sensory room has not been used recently. At the last inspection a requirement was made for the equipment to be repaired so that the room could be used. The manager said that they have spoken to residents about it and they no longer wish to use it as a sensory room. The equipment is being disconnected and an alternative use will be found for this room. One of the residents may use some of the equipment in their bedroom. The open plan lounge and dining room have been redecorated in the last year. The lounge is carpeted and there is a wooden floor in the dining room to make it more practical. The kitchen worktops have been lowered. However, residents said that they are still not low enough for them to be able to help staff in the kitchen with the preparation of food. The home was clean, with the exception of one resident’s bedding, and free from offensive odours. The fridge door handle and seal were broken. The manager said that these have been reported to the maintenance department. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35 An effective staff team supports the residents. Residents are not sufficiently protected by the homes recruitment practices. Staff have not received the appropriate training to meet all the residents needs. EVIDENCE: The manager said that there is now a core team of agency staff who work at the home. Two members of staff have left since the last inspection. A deputy manager has been in post since September 2005. Three new staff have recently been recruited and are awaiting the necessary checks before they can start working at the home. There are two members of staff on duty at night, 1 sleep in and 1 waking night staff. All staff including agency staff were on the rota to attend the staff meeting the next day. Residents told the Inspection Team, “The staff are very good.” The Inspection Team thought that the staff communicated well with the residents. The manager showed a memo addressed to Human Resources dated 24th September 2005 requesting references, health questionnaires and evidence that Criminal Record Bureau checks have been undertaken for several staff, so that these can be available in the home as required. This remains outstanding. The manager said that training in adult protection remains outstanding. They are awaiting a date for staff to attend fire safety training. All staff have had manual handling training. All staff will be attending training in managing challenging behaviour by the end of November 2005. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 21 All but one member of staff have almost completed accredited training in the ‘Safe Handling of Medicines’. The manager said that all staff have had a performance development review this year. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 Arrangements are adequate to ensure that residents benefit from a well run home. Adequate arrangements are not in place to ensure that the health, safety and welfare of residents is promoted and protected. EVIDENCE: Since the last inspection the manager has been registered by the CSCI. The manager has many years of experience of managing care homes for people who have a learning disability. The manager was a registered care manager in another home in Birmingham for several years. Records showed that the hoists and residents wheelchairs were serviced in September 2005. An engineer completed the five-year electrical wiring test in May 2002 and stated that it was in a satisfactory condition. The portable electrical appliances were tested in May 2005. The Inspection Team did not notice any easy to understand fire procedures displayed around the home. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 23 The manager said that a fire officer had visited in the morning. The Fire Officer raised some concerns about the intumescent strips on six of the fire doors that were not properly sealed. This would not prevent a fire and smoke from spreading around the home. This had been reported to the maintenance department already. Some self- closing fire doors were not maintained properly so that they won’t close firmly and prevent a fire from spreading. The Fire Officer also raised concerns about the open plan design of the home. The Fire Officer recommended that the outside doors in resident’s bedrooms be fitted with thumb-turn locks on the inside and have a suited master key which is carried by all staff at all times to allow access to bedrooms via either the internal or external doors. Staff have not received training in fire safety. The manager said that they are waiting for a date to be set for this. The water temperatures are tested regularly and are within safe limits so that they are not too hot or too cold for residents. All room temperatures are tested weekly as in the past there have been some problems with the storage heaters not providing enough heat to keep some of the bedrooms warm at all times. Thermometers are provided in all bedrooms so that these can be checked regularly. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 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 x x x x x Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 2 2 2 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score x x 3 2 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ferndale Crescent, 10 Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 1 x DS0000016880.V269760.R01.S.doc Version 5.0 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 YA1 Regulation 5 (1) (2) Requirement Timescale for action 31/01/06 2. 3. 4. 5. 6. 7. 8. 9. YA19 YA19 YA20 YA27 YA28 YA29 YA30 YA30 The service users guide must be available in the home. The statement of purpose must be updated to reflect the changes in the management arrangements. (Not assessed at this inspection) 12 (1) (a) Each resident must have a Health Action Plan in line with ‘Valuing People’ 12 (1) (a) Residents must be weighed monthly and a record of this kept. 13 (2) Protocols must be in place for all PRN (as required) medication. 16(2)(k)23(2)(b, The shower in one residents c) en suite must drain away efficiently. 23 (2) (h) An alternative use must be found for the sensory room. 23 (2) (n) The kitchen worktops must be lowered so that they are accessible to all residents. 23 (2) (b) The fridge door handle and seal must be repaired. 16 (2) c, 23 (2) Residents must have clean (d) bedding at all times. DS0000016880.V269760.R01.S.doc 31/01/06 31/01/06 31/12/05 31/12/05 28/02/06 31/01/06 30/11/05 10/11/05 Ferndale Crescent, 10 Version 5.0 Page 26 10. YA34 11. YA23YA35 12. YA42 13. 14. YA42 YA42 15. YA42 16. YA42 The following records must be available in the home for all staff employed there: completed application form, two written references, completed health questionnaires and evidence that a Criminal Records Bureau check has been undertaken. 12(1)(b)18(1)(a All staff must receive c) training in: a) Adult protection b) Care planning (Previous timescales of 31/01/05 & 30/09/05 not met) c) Cultural awareness (Previous timescales of 30/04/05 & 30/09/05 not met) d) Managing behaviour 13 (4) (a, b, c) COSHH assessments must be in place for all hazardous substances used in the home. (Not assessed at this inspection) 18(1)(ac)23(4)d, All staff must receive e training in fire safety. 13(4)23(4)(a- c) All self-closing fire doors must be maintained so that they close firmly onto their rebate. 13(4),23(4)(a– Intumescent strips must be c) repaired on the identified fire doors in order to provide an effective barrier to smoke. 13(4) 23 (4)(a– All external bedroom doors c) must have thumb-turn locks fitted on the inside. A suited master key must be provided that is carried by all staff at all times to allow access to bedrooms via either he internal or external doors in case of fire. Schedule 2 (5 – 8) DS0000016880.V269760.R01.S.doc 31/12/05 28/02/06 31/01/06 31/12/05 31/01/06 31/01/06 31/01/06 Ferndale Crescent, 10 Version 5.0 Page 27 Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 28 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. 2. 3. 4. 5. Refer to Standard YA6 YA14 YA14 YA16 YA42YA22 Good Practice Recommendations Person centred plans should be developed further for each resident. The resident who stated that they would like to go to see Birmingham City play should be supported to do so. All residents should be supported to go on holiday each year. The use of the current sensory room as the laundry should be considered. There should be easy to understand fire and complaints procedures displayed in the home. Ferndale Crescent, 10 DS0000016880.V269760.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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