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Inspection on 05/07/05 for 115 Gough Road

Also see our care home review for 115 Gough Road for more information

This inspection was carried out on 5th July 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a team of enthusiastic staff who have a good knowledge of the needs of the people in their care. Meals served at the home are at flexible times with a choice of food available depending on the personal preferences of service users. Cultural and religious needs of individuals are taken into account when planning menus. Staff at the home seek input from other health and social care professional to assist in meeting individual need. The home and SENSE as an organisation is commended for the work it does in encouraging individuals to maintain and develop contact with their family. People who live at the home take part in a variety of daytime activities including swimming, rock climbing, gym, ice skating, horse riding and rambling. The care plans for individual are informative as to the support they require from staff.

What has improved since the last inspection?

Health action plans have been introduced. This is a plan that records everything an individual needs to stay healthy. Some internal redecoration has taken place making the environment a more pleasant place to live.

What the care home could do better:

Work needs to be done on the ways in which risks are assessed and how this information is presented. Work needs to be done to track the reasons why some activities do not take place, identifying any common themes. Staff must do more training so that they have the skills and knowledge to do their job and support the deaf/blind people. Issues relating to fire safety require improvement. Some requirements from previous inspections remain outstanding. The provider needs to ensure they are addressed.

CARE HOME ADULTS 18-65 Gough Road 115 Gough Road Edgbaston Birmingham B15 2JG Lead Inspector Kerry Coulter Announced 5 July 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. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gough Road Address 115 Gough Road, Edgbaston, Birmingham B15 2JG 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 446 6744 0121 446 6289 Sense West Sue Laight (Acting) Care Home 5 Category(ies) of Learning Disabillity & Sensory Impairment (5) registration, with number of places Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2004 Brief Description of the Service: 115 Gough Road is a large detached Victorian house situated in a quiet residential road in Edgbaston. Public transport is close by and the home is approximately two miles from the city centre of Birmingham. Gough Road currently accommodates five male service users. The accommodation is spacious and includes a large reception hall, lounge, dining room, kitchen, office/meeting room, laundry and a ground floor bedroom with ensuite facilities. Four further bedrooms, (one of which is ensuite), two bathrooms and a toilet are situated on the first floor. The home has a second floor, which is inaccessible to service users, and provides a storage area and a staff sleeping in room. The garden has been developed so that the top area includes a large patio area which is accessible to service users and contains garden furniture and a range of plants. The lower part of the garden is extensive and a decision has not yet been reached regarding its development. The home provides care and support services to five adults with learning disabilities and a sensory impairment. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 the deaf/blind people were limited due to their complex needs and limited verbal communication abilities. However, the inspector spent time with the deaf/blind people observing care practices, interactions and support from staff. A tour of the home 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 to the Acting Manager, Deputy Manager, Assistant General Manager and informally with support workers. In addition to information provided in response to the pre-inspection questionnaire, feedback was received from the General Practitioner (GP) and the Chiropodist. What the service does well: What has improved since the last inspection? Health action plans have been introduced. This is a plan that records everything an individual needs to stay healthy. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 6 Some internal redecoration has taken place making the environment a more pleasant place to live. 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. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 5 The Service User Guide is inadequate and does not provide sufficient information for service users to be clear about the services the home provides to meet their needs. EVIDENCE: Since the last inspection in November 2004 the home has further developed the Statement Of Purpose and Service User Guide. The Statement Of Purpose did not contain a summary of the complaints procedure. The Service User Guide was available in a written format, was very brief and did not contain an adequate summary of the statement of purpose. The General Manager stated that these documents were again due for review as a standard SENSE format was being developed. Work is also underway to make them available in alternative formats to include audiotape, photos, CD Rom and picture, thereby increasing their accessibility to the people who live at the home. Previous inspections have required that people who live at the home must be provided with an individual contract and terms and conditions of residency. The Deputy Manager stated that progress was being made towards achieving this and that two individuals now had a signed contract and that conditions of residency agreements were under development. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet individual need. 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: The records of three people who live at the home were sampled. Each person had a plan of care. The plans sampled were up to date, detailed, informative and included behaviour management guidelines. 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. The home has the services of a Practice Development Worker who works with other staff on the development of care plans. Part of the PDW role is to undertake practice observations of staff working with deaf/blind people. SENSE has documentation to be completed following the observation. It is recommended that the document is amended to record if staff practice is in line with the care plan as this appears to be part of the purpose of the observation. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 10 Members of staff actively encourage each deaf/blind person 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 were sampled for people who live at the home. Whilst the assessments sampled were up to date further development is required. Some assessments were generic, this means that they are not specific to the individual. This was the case for an assessment regarding epilepsy, this needs developing to ensure it is specific to the individual who is at risk of having a seizure. 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. Work also needs to be undertaken to ensure each risk assessment includes the level of risk, i.e. low, medium or high. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 A range of activities is offered in order to promote personal development, participation in the life of the local community and enjoyable leisure time but the quality of the recording of cancelled activities is variable. Staff offer appropriate support to enable individuals to maintain contact with relatives. Healthy and nutritious meals are provided and people who live at the home exercise choice about what they eat. EVIDENCE: Each person who lives at the home has a schedule of activities. The activities on offer are varied and include swimming, shopping, rock climbing, ice-skating and massages from a visiting therapist. Records of activities sampled required improvement. Sometimes it was recorded that the scheduled activity did not take place and an alternative was offered, but the reason for this was unclear. For example, a planned activity might be cancelled due to a lack of driver, individual choice or it could be Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 12 cancelled by the venue. The recording must improve to enable staff to track why activities are not taking place and adjust the schedule if necessary. People living at the home access the local community in terms of shops, parks and other facilities. The home has a minibus, which is unlabelled. Discussion with the Acting Manager and Deputy indicates that the home is soon to benefit from a second vehicle and it is anticipated this will increase the opportunities for activities. 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. It is an area of good practice that SENSE employs a Family Liason Officer. Additionally, a family weekend is also arranged at a local hotel where relatives can meet with SENSE representatives and other relatives. The food cupboards, fridge and freezer were well stocked, and meals and menus were seen to more than satisfactory. A lunch time meal was observed. Staff ate with people who live at the home and support was offered in line with sampled care plans. Two individuals at the home are Muslim in terms of their culture and the home provides separate food storage for their Halal foods. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 Health needs are generally appropriately met, and positive action is being taken to make further improvement. Practices relating to the storage and administration of medication are generally satisfactory but auditing of stock must be introduced. EVIDENCE: Records show that referrals are made to healthcare professionals as and when required. Accident records indicate that the home has a low level of accidents involving people who live at the home. A new format for Health Action Planning has been introduced recently. 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. Two CSCI comment cards were received from health professionals involved with the home. Neither of these raised any concerns with the care provided. Not all staff at the home have received accredited medication training, the Acting Manager stated that dates have been arranged for the required staff to attend Safe Handling of Medication Training. In general the procedures for medication administration are satisfactory. Medicines were seen to be stored Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 14 appropriately in a secure location. The majority of medication is dispensed from a blister pack but Paracetamol is retained in the manufacturers packaging. The home needs to introduce regular audits of non-blistered medication to ensure stocks held in the home tally with medication administered. Regular auditing will identify any discrepancies. Protocols are available for the administration of ‘as required’ medication. One protocol on medication to relieve constipation recorded that it should be given if the individual has not been to the toilet in a three day period. Unfortunately staff in the home are not completing the tracking records for this on a daily basis. This could mean that the individual would not receive the medication when required. This was raised with the Acting Manager who was able to evidence that she had raised this issue with staff at a meeting in June, five days prior to the inspection. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 complaints system in the home is satisfactory. The arrangements in place to protect the people living in the home from the possible risk of harm or abuse are satisfactory. EVIDENCE: The homes complaints log indicated that no complaints had been received by the home. Following a requirement made at the previous inspection the home now has the complaints policy available on CD Rom. The Deputy Manager stated that it was also intended to further develop a pictorial format. People 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 home has a flow chart for staff to follow in regards to adult protection. This had not been fully completed but was rectified at the time of the inspection. The file of one recently recruited staff evidenced that a robust recruitment procedure had been followed. Records evidence that staff receive training in adult protection to ensure they are aware of the signs of abuse and respond appropriately. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 Recent repainting has improved the appearance of this home creating a comfortable and safe environment for those living there and visiting. Work to refurbish the kitchen now needs scheduling to ensure all areas of the home are well maintained. EVIDENCE: The premises are not owned by SENSE, the landlords of the property are Moseley and District Churches Housing Association. In the main the home is well maintained and decorated to a reasonable standard. The outside of the premises and several internal rooms have been repainted as required at the last inspection. People who live at the home are provided with a single bedroom. Bedrooms sampled were observed to be personalised according to individual needs and preferences. The kitchen area is starting to look worn in appearance. Worktops have some chipped areas and the area to the back of the sink requires resealing. The rear kitchen, where most of the food is stored has some missing drawer fronts and Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 17 one jammed drawer. Refurbishment of the kitchen areas needs to be scheduled. 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. The house is kept clean and tidy, and hygiene is maintained to a good standard. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 Staffing levels are appropriate to the needs of people living at the home. There is a continuous training programme in place for staff, and this should be developed further to ensure staff receive all mandatory training. The homes recruitment practices safeguard individuals. Staff are generally well supported, but formal supervision in accordance with required standards needs to be better established. EVIDENCE: It was noted that both staff and people who live at the home appear comfortable in each other’s company. Members of staff demonstrate that they have a good personal knowledge of the individuals in their care. Information provided in response to the pre-inspection questionnaire confirms that 44 of the staff team are qualified to NVQ 2 or above, falling just short of the target of 50 . The training matrix examined indicated that some staff required updates in mandatory areas. The pre inspection questionnaire completed by the Acting Manager records that 490 staff hours are provided per week for the five individuals who live at the home. The home aims to provide four support staff during the day, with the Acting Manager and Practice Development Worker hours being in addition to Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 19 this. Staffing numbers provided appear to be satisfactory to meet the needs of people living at the home. There is some use of agency staff in the home to cover deficits as the home currently has a total of 3.5 vacant staff posts. The Acting Manager stated that agency hours usually average 100 hrs per month but increased recently when 1:1 support was provided to an individual admitted to hospital. 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. The frequency of supervision from managers was assessed for four staff. Two staff had received regular supervision, another had not received supervision since January. Records were not available for the fourth member of staff, the Acting Manager stated these records were currently with SENSE’s personnel department. Staff should receive supervision at least six times a year to ensure they are fulfilling their responsibilities and receive appropriate support. The records of one recently employed member of staff were sampled. This evidenced that robust recruitment procedures had been followed. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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) 37, 39 and 42 An effective quality assurance system is in place. Work practices in the Home generally promote and protect service user’ welfare, health and safety but attention is required to fire safety. EVIDENCE: The home has an acting manager in post who was previously the deputy of the home. A permanent manager is due to start in July. The organisation must forward an application to register the new manager. 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. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 21 The fire safety records were examined and all tests, checks, servicing of equipment and drills had been completed or scheduled as appropriate. Fire training had taken place in May for most staff but arrangements need to be made to ensure all staff have received this training to include night, new and casual staff. The home has a fire risk assessment but this was observed to require review. It was observed that not all doors in the home had effective smoke seals, for example this was missing on the dining room door. The Acting Manager stated some smoke seals had been removed or over-painted during the recent redecoration and that this had been reported to the landlord of the premises. Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 x x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 3 3 3 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 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gough Road Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 2 x E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 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 4 Requirement The home’s statement of purpose must include the following information: The fire precautions and emergency procedures. The arrangements for dealing with complaints. Outstanding requirement from 31/3/04. The home’s service user guide must include the following information;· Summary of statement of purpose. Outstanding requirement from 31/3/04. The home must ensure that each service users has a signed contract. Outstanding requirement from 31/3/04. Risk assessments require further development to ensure they are specific to the individual where appropriate, detail the level of risk and cross reference to the care plan. The home must effectivley monitor the number of planned activities that do not take place. Improvement is needed to the recording of why planned activities do not occur and how choice of alternative activrties Timescale for action 30/8/05 2. 1 5 30/9/05 3. 5 5 30/9/05 4. 9 13(4) 30/8/05 5. 12 16(2)(mn) 30/8/05 Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 24 was made. 6. 7. 20 24 13(4) 23(2) A system for the auditing of non blistered medication stocks must be introduced. The kitchen areas require refurbishment to include worktops and repairs or replacement of broken doors. Proposed timescale for this to be done to be notified to the CSCI. Ensure staff have received all mandatory training to incude refresher training. Outstanding from 31/4/04. Ensure staff receive supervision at least six times a year, preferably monthly. Records of supervision must be available in the home. The Work Place Fire Risk Assessment required review. Some smoke seals around doors require repair or relpacement to ensure an effective seal against smoke/fire. Ensure all staff receive fire training at least six monthly to include night and casual staff. 30/8/05 30/8/05 8. 35 18(1)(c ) 30/8/05 9. 36 18(2) 30/8/05 10. 42 13(4) & 23(4) 13(4) & 23(4) 13(4) &(23(4) 11. 42 12. 42 5/8/05 Immediate requiremen t 30/7/05 Immediate requiremen t 30/8/05 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 6 Good Practice Recommendations Record of practice observations- It is recommended that the document is amended to record if staff practice is in line with the care plan as this appears to be part of the purpose of the observation. it is recommended that the frequency of staff meetings is increased. 2. 33 Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 25 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 Gough Road E54_S16712_GoughRoad_V229332_050705 Stage 4.doc Version 1.30 Page 26 - 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!