Inspection on 28/09/05 for 428-430 Gillott Road

This inspection was carried out on 28th September 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

428-430 Gillott Road 28/12/06

428-430 Gillott Road 23/02/06

428-430 Gillott Road 10/01/05

428-430 Gillott Road 08/09/04

428-430 Gillott Road 09/12/03

428-430 Gillott Road 26/08/03

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Harmony Care Home

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Bryndale Avenue, 41 Flats 13, 14 & 18

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

CARE HOME ADULTS 18-65 Gillott Road 428-430 Gillott Road Edgbaston Birmingham B16 9LP Lead Inspector Kerry Coulter Announced 28 September 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. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Gillott Road Address 428-430 Gillott Road, Edgbaston, Birmingham B16 9LP 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 454 9293 0121 455 8256 Sense West Vacant Care Home 8 Category(ies) of learning Disability - Sensory Impairment (8) registration, with number of places Gillott Road E54 S16714 GillotRoad V245362 270905 AI 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 10th January 2005 Brief Description of the Service: 428-430 Gillott Road is registered to provide personal care and support to 8 adults with a visual impairment/ learning disability, who have been assessed as requiring full assistance with daily living tasks. The premises are divided into two homes, each with its own team of staff. Each has its own front door but is also internally interlinked. The home is staffed 24 hours a day including waking night and a sleeping in member of staff. Service users would be admitted to the home following a full assessment that would determine the level of support they require. A number of adaptations have taken place within the home in order to meet the assessed needs of the service users. Service users are encouraged and supported to maintain links with their families and the local community. The home is situated in Edgbaston, a residential area of Birmingham and has ready access to local amenities. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and was carried out over seven hours. This was the first of the statutory inspections for this home for 2005/2006. During the inspection a tour of the premises was made, service user and staff files were sampled as well as other care and health and safety records. The Inspector spoke with the Manager and members of staff and met with some of the service users. 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. Information has also been obtained from the pre inspection questionnaire. 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? 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. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 6 A new worktop has been fitted in the kitchen of house 430 as previously required by the Environmental Health Officer. A new lounge carpet has also been fitted making this room a more pleasant area to spend time in. Staffing has improved since the last inspection, four additional staff have been recruited and funding for eight hours a day 1:1 support for one service user has been agreed. 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. Gillott Road E54 S16714 GillotRoad V245362 270905 AI 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 Gillott Road E54 S16714 GillotRoad V245362 270905 AI 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 information about services provided but alternative formats are not available. Assessment and admission procedures are satisfactory. EVIDENCE: The home does not have any service user vacancies. All of the service users who live at the home have done so for over ten years. Previous inspections have evidenced that full assessments have been completed for current service users and that the admission procedure for prospective service users is satisfactory. The statement of purpose and service user guide were observed to contain all of the required information to provide service users with the information they need. However the service user guide is only available in a type written format. Due to the needs of the service users consideration must be given to providing the guide in alternative formats to include photographs, CD Rom, audio or video tape as suitable to individual need. Gillott Road E54 S16714 GillotRoad V245362 270905 AI 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, 9 and 10 There is a clear and consistent care planning system in place to provide staff with information they need to meet service user needs. Risk assessments required development and not all had been kept under review. These shortfalls have the potential to cause inconsistencies in the care given to the service user and place them at risk. EVIDENCE: The files for three service users were sampled. Care plans were up to date. They included detailed personal profiles, personal goals and aspiration, specific information on service users communication needs and independence and life skills. In addition, some service users have individual support strategies and guidelines, in some cases devised by professionals working in partnership with staff in the home. 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. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 10 The home has completed a wide range of service user risk assessments, these include swimming, rambling, ice skating and self injurious behaviour. The risk assessments sampled in one of the homes were up to date but this was not the case in the other home where risk assessments were dated as reviewed in July 2004. 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. Service users individual records are stored securely. Staff are mindful of issues discussed in the presence of service users, and were not observed breach confidentiality. The home uses accident books that are compliant with the Data Protection Act. Gillott Road E54 S16714 GillotRoad V245362 270905 AI 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) 11, 12, 13, 14, 15, 16 and 17 The home actively encourages and supports individuals to develop social skills and in continuing their educational needs and preferences. Intergration within the community and pursuit of leisure activities are integral elements of the ethos of the home. Staff support service users to maintain and develop relationships with family and friends. Dietary needs of service users are well catered for with a balanced and varied selection of food available. EVIDENCE: Service users have a varied and full timetable of in-house or community based activities. Independent living skills are planned into individual activity programmes All of the service users participated in activities external to the home during the inspection, this included shopping and rock climbing. The case files detail that a wide range of services, facilities and activities are accessed. This includes meals out, ice skating, horse and cart, pubs, parks, local shopping trips and other outings. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 12 Service users at the home have access to a range of leisure activities. This includes video, music systems, television, board games and a recently purchased electric massage chair. Service users have had the opportunity to go on holiday, destinations this year have included Cornwall, Bude, Lanzerote and Portugal. The home has it’s own vehicles which are used to enable service users to pursue their chosen activity. Service users pay a percentage towards transport costs. It was evidenced at the inspection in September 2004 that this has been agreed with relatives and the funding authorities. House 430 is short of drivers, this situation will need to be monitored to ensure service users are getting value for money for the contributions they pay towards the vehicle. 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. Three service users recently went on a day trip to London to meet up with relatives. It is an area of good practice that SENSE employs a Family Liaison Officer. Additionally newsletters are sent out by SENSE, a family weekend is also arranged annually at a local hotel where relatives can meet with SENSE representatives and other relatives. The food records sampled evidenced there was a good variety of meals on offer. Food stocks in the home were good and there was fresh fruit and vegetables available. The Manager stated that service users are encouraged to participate in food shopping for the home and have the opportunity to choose foods that they have a preference for. Gillott Road E54 S16714 GillotRoad V245362 270905 AI 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) 18, 19 and 20 Further development of the homes healthcare monitoring systems were required so that the home can evidence that service users needs are properly monitored and kept under review. The systems for the administration of medication require improvement to ensure service users receive the medication they need. EVIDENCE: Appropriate guidance and support is given to service users who require assistance with personal hygiene. This is clearly documented in care plans. 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 to include the Speech and Language Therapist. However it was not evident if all service users had regular medication reviews. The Manager will need to liaise with the GP or Community Nurse allocated to the GP surgery to ensure this is arranged. 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. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 14 Good work has been done in seeking to identify and systematically record individuals’ health needs but further work needs to be done to include any health support required regarding epilepsy and to detail medication reviews. Some improvements are required to the system for the safe administration of medication. Topical cream was observed to be stored for one service user with no pharmacy label or date of opening. The directions for the administration of the cream need to be available on the packaging along with the date of opening so that it can be discarded 28 days after opening. Some tablets were stored that had been dispensed more than six months previously, new tablets will need to be obtained and the old ones returned. A copy of the prescription is not retained, this must be done so that staff checking in the medication can check the medication against the prescription. Controlled medication is stored in the home, this is checked and signed for daily in the co-ordinators file on loose sheets of paper. A bound controlled drug register must be purchased for this purpose. The location of the medication cabinet in the kitchen needs to be reviewed. It is quite high making it difficult for any staff who are smaller in height to easily see what is stored on the top shelves. The cabinet is also located behind a door. People entering the kitchen would not be able to tell if someone was behind the door using the medication cupboard. This poses a risk to staff and could also disrupt the safe administration of the medication. A random audit of stocks held revealed no discrepancies, and there were no gaps on the administration record. It is good practice that clear descriptions have been completed on how service users prefer to take their medication. Protocols have also been completed for any medication that is prescribed on an ‘as required’ basis. Gillott Road E54 S16714 GillotRoad V245362 270905 AI 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 has a satisfactory complaints system. Physical intervention recording and CRB checks is lacking for some staff and impacts on the homes ability to ensure that service users are being protected from abuse and that their welfare is being promoted. EVIDENCE: Discussion with the Manager and the complaints log indicated that no complaints had been received by the home. Following requirements made at previous inspections the home now has the complaints policy available on CD Rom. Service users who live at the home are reliant on staff that know them well to pick up on cues and clues as to whether or not they are happy. Conversations with members of staff indicated that they have a good knowledge of individuals’ ways, and are sensitive to people’s non-verbal communication. The CSCI have been informed of some incidents where physical intervention had been used but not all. Records on the use of physical intervention were sampled. Some records were very detailed but others did not record the length of the intervention, why it had been used and the staff involved. Records on the use of physical intervention require improvement to ensure they meet the Department of Health guidance for restrictive physical interventions (2002) and to show that service users are not subject to unnecessary intervention. The majority of staff at the home have received Protection of Vulnerable Adults training, only staff new to the home are still to attend and this has been arranged. The home has an adult protection procedure and a copy of Birmingham Multi Agency guidelines are available. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 16 SENSE’s policy states that all current staff will have had a Criminal Records Bureau (CRB) check by 2004. It is therefore disappointing that several staff still have not had a check completed and only applied for a check a few weeks prior to this inspection. CRB checks are required to ensure that the right people are working with service users, ensuring their protection. CRB checks had been completed prior to new staff commencing work in the home. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 17 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 Several routine maintenance matters required attention to ensure the home presents as a homely and comfortable environment for the people who live there. EVIDENCE: Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 18 The home is decorated in bright contrasting colours to meet the needs of service users with a visual impairment. Around the home there are tactile indicators to indicate to service users where doors, stairs and other hazards are. The lounges, dining areas and kitchens also have tactile indicators. The safety systems are appropriate for people with visual and associated impairments. There are buzzers and flashing lights to alert service users. The home was comfortable and domestic in style. Since the last inspection a new carpet has been fitted in house 430 and the shower room in 428 has been converted into a wet room. Some of the bedrooms do not have the furniture and fittings to meet the minimum standards. The Manager said that this due is to the fact that the service users in those rooms will not tolerate any additional furniture. Where a service user does not wish the furniture and fittings this has be recorded in the care plan and reviewed on a regular basis. One service user will not tolerate having a wash hand basin. A second bedroom was also without a wash hand basin, no evidence was provided that the provision of this facility would pose a risk. This must be reviewed and a wash hand basin provided if appropriate. Several routine maintenance matters were highlighted and raised concern regarding the general safety of the premises and upkeep of the house. Staff said that the water temperature of the shower often fluctuates between hot and cold. This problem will need resolving to ensure the water is maintained at a safe and comfortable temperature for service users. Staff have attempted to make the bathroom in 430 more homely by painting the tiles. Unfortunately the paint has started to peel. The refurbished wet-room has several areas where the walls require repainting. One service user had a broken window in his bedroom, this has been boarded up for several weeks. The Manager stated that a new window was on order and that staff had tried to chase up the matter with the landlords several times to speed things up. An immediate requirement was made at the time of the inspection for the window to be repaired. A capital bid for funding has been made to provide a walk in shower for one service user. This needs to be agreed as soon as possible to ensure work can start to provide showering facilities that are more suitable to his needs. The rear garden is enclosed and well maintained. Staff said that it was intended to purchase a greenhouse in the near future so that service users can become more involved in growing plants. The premises are kept clean, hygienic and free from offensive odours. A new worktop has been fitted in the kitchen of house 430 as previously required by the Environmental Health Officer. The home has a laundry room. It is sited away from areas where food is stored, prepared and eaten. Policies and procedures are in place for the control of infection and include the safe handling and disposable of clinical waste. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 19 The Manager must ensure that fridge and freezer temperatures are monitored on a daily basis to ensure food is stored at a safe temperature and service users are protected from the risk of food poisoning. Gillott Road E54 S16714 GillotRoad V245362 270905 AI 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) 33, 34, 35 and 36 Current staffing arrangements are at times failing to meet the needs of the service users. EVIDENCE: Staffing has improved since the last inspection, four additional staff have been recruited and funding for eight hours a day 1:1 support for one service user has been agreed. Unfortunately the home is still having to use agency staff to cover for some long term staff absences. The home has three full time vacancies, the Manager said that some interviews for new staff had taken place with further interviews planned. The organisation needs to ensure the current use of agency staff is further reduced to ensure service users are supported by people they know. Staff meetings are held, but minutes available in the home indicate meetings are not always held monthly. It is recommended that the frequency of meetings is increased to monthly to ensure staff can discuss relevant issues and are kept updated. Staff files were sampled. Files for newly recruited staff contained all the required information to evidence that a robust recruitment process had been followed. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 21 However, for some staff who have worked at the home for some time Criminal Record Bureau checks have not been received, as stated earlier in this report. Training records and discussion with the Manager show that SENSE has a rolling programme of training but some mandatory training was outstanding. Some staff required fire and manual handling training whilst the training records for one long term staff did not show that they had done physical intervention training. The pre inspection questionnaire records that 85 of staff have completed an NVQ in care. The frequency of supervision from managers was assessed for two staff. Staff receive supervision at least six times a year to ensure they are fulfilling their responsibilities and receive appropriate support. Records evidence that identified areas of poor performance are addressed. Gillott Road E54 S16714 GillotRoad V245362 270905 AI 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, 39 and 42 The health, safety and welfare of the service users had not been adequately promoted and protected. EVIDENCE: The home does not have a registered manager, however an application has been received to register the current manager. The application received indicates that the Manager has many years experience of working with people who have a learning disability and sensory impairment. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 23 Systems are in place to measure the quality of the service the home provides. This includes monthly visits to the home by the general manager who completes a report and forwards this 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. Action plans have been completed as a result of audits undertaken. There are some concerns regarding the homes compliance with relevant Health and Safety legislation. There were some gaps in the records for testing of fire alarms and emergency lighting. Some staff were overdue for fire training although arrangements for staff to receive training via a training video have been made. The certificate for the hard wiring system records that some areas are unsatisfactory but evidence was not available to show that all the work required had been carried out. Gillott Road E54 S16714 GillotRoad V245362 270905 AI 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 2 3 2 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 4 3 3 Standard No 31 32 33 34 35 36 Score x x 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gillott Road Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 2 x E54 S16714 GillotRoad V245362 270905 AI 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 5(1) Schedule 4 (2) Requirement The service user guide must be in a format to meet the needs of service users. Consideration must be given to the use of photographs, CD Rom, audio or video tape, or evidence of explanation as suitable to individual need. Outstanding requirement from 31/3/04 The provider must ensure that all service user risk assessments are reviewed at least six monthly. Risk Assessments must cross reference to service users care plans. The risk assessment must clearly record the level of risk. Ensure any medication prescribed to service users is reviewed with the GP/Consultant at least annually, with a record maintained in the home. The provider must ensure that any controlled medication received into the home is recorded in a bound controlled drugs register. Topical creams and ointments must be dated on opening and discarded after 28 days. Medication should only be stored Timescale for action 30/12/05 2. 9 13(4) 28/10/05 3. 9 13(4) 30/11/05 4. 19 12(1)(2) & 13(2) 28/10/05 5. 20 13(2) 28/10/05 6. 20 13(2) 30/10/05 Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 26 7. 8. 23 23 37 12(1) 13(6,7,8) 9. 10. 24 & 26 24 23(2)(b) 23(2)(b) 11. 26 23(2)(j) 12. 27 13(4) & 23(2)(j) 13. 27 & 29 23(2)(j, n) 14. 30 16(2)(h,j) 15. 33 12(1) & 18(1)(a) in the home for a maximum of six months after dispensing before being returned and new supplies ordered. Copies of prescriptions must be retained in the home, in line with Sense policy. Accidents/incidents to include the use of physical intervention must be notified to CSCI. Records on the use of physical intervention require improvement to ensure they meet the Department of Health guidance for restrictive physical interventions (2002). Ensure the window in service user bedroom is repaired with safety glass. Attention is required to the peeling paint on the tiles in one bathroom and repainting of walls in the wet room. The lack of a wash hand basin in one service users bedroom must be reviewed. One must be provided if appropriate. The problem of fluctuating water temperatures to the shower must be resolved. Records of water temperatures must be maintained. The service user in ground floor bedroom must be provided with showering facilities suitable to his assessed needs. Action plan required. The Manager must ensure that fridge and freezer temperatures are monitored on a daily basis to ensure food is stored at a safe temperature and service users are protected from the risk of food poisoning. The home needs to resolve the issues of staff who are absent form work and reduce the use of agency staff. 30/10/05 30/11/05 5/9/05 30/11/05 30/12/05 15/10/05 30/11/05 1/10/05 30/11/05 Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 27 16. 17. 34 35 13(6) & 19 18(1)(c ) 18. 42 13(4) 19. 20. 42 42 13(4) & 23 13(4) & 23 Criminal Record Bureau checks must be obtained for all staff working at the home. Staff must receive training in all mandatory areas. A training plan must be forwarded to CSCI that includes fire, manual handling and physical intervention. Ebsure evidence is available in the home to show that electrical repairs have been done, as required on the hard wiring certificate. Ensure that the fire alarms and emergency lighting are tested weekly/monthly. Ensure staff receive fire training six monthly. 30/11/05 30/11/05 14/10/05 29/9/05 28/10/05 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 20 Good Practice Recommendations The medication cabinet in the kitchen should be relocated to a more convenient location. Gillott Road E54 S16714 GillotRoad V245362 270905 AI stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Birmingham & Solihull Local Office 1stFloor, 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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