Inspection on 18/11/06 for 56-58 Gravelly Hill

This inspection was carried out on 18th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

56-58 Gravelly Hill 13/03/08

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Gravelly Hill, 56-58 Erdington Birmingham B23 7PF Lead Inspector Sean Devine Unannounced Inspection 18th November 2006 08:30 Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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 Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gravelly Hill, 56-58 Address Erdington Birmingham B23 7PF 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) 0121 328 0612 01952 610996 Caretech Community Services Limited Mrs Sharon Ralphs Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate 3 services under 65 for reasons of learning disability. 5th January 2006 Date of last inspection Brief Description of the Service: 56 Gravelly Hill is a traditional terraced house. There is accommodation for two younger adults with a learning disability no residents are currently accommodated. 58 Gravelly Hill as with house 56 is a traditional terraced house and currently accommodates one younger adult with a learning disability. The home is in Erdington, a residential area of Birmingham. It is in walking distance of shops, pubs, parks, places of worship and public transport. The manager advised on pre inspection information that the fee for the home for the current resident was £4,671.12 each week. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was unannounced over one day (5hrs) by one regulation inspector. Records about the social and health care of the resident were seen including care plans and medication, and staff informally discussed their practices. Health and safety records, tests and servicing were sampled and a tour of the communal areas of the home was completed. The inspector was able to meet the resident, and discuss care practices with a senior support worker and an agency member of staff. The resident has a learning disability, which does at times impair the ability of the resident to effectively communicate and therefore their views and opinions of the service are at times unclear. Records about complaints were seen, there have been no complaints to the home by the resident or their representatives and the Commission has not received any in the past twelve months. At the end of the inspection important issues were fed back to the senior support worker, including the concerns about health and safety, this was in part made safe at the time of inspection and following inspection the manager advised that unsafe electrical items had been made safe. Prior to the visit an inspection questionnaire and a survey letter were sent to the home. The manager completed the questionnaire and an advocate of the resident completed the survey, both were returned to the Commission. What the service does well: The resident has comprehensive assessments of needs; these have included personal choices and preferences. Many care plans and risk assessments have been written clearly and concisely and include these personal choices and preferences. The care plans inform staff of what they must do to support the resident and the risk assessments inform staff what steps they must take in order to reduce risks to the resident and other people. The resident is able to engage in chosen activities and the staff have supported this through rigorous risk assessments. This includes learning some life skills. The home actively involves other relevant people in the planned care, including an advocate to at times represent the resident and healthcare professionals. The manager ensures staff are safely recruited and they are available in good numbers to meet the needs of the resident. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 6 The advocate who returned the survey positively praised the manager and staff for their support within her role of advocating for the resident. What has improved since the last inspection? 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. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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 the following standard(s): Standards 1,2 and 5. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the ability to enable residents to choose a home that will meet their specific needs and that the home consider and decide on whether they are able to meet the assessed needs. This ensures residents are not inappropriately admitted and that their needs will be met. EVIDENCE: The home has in place a statement of its purpose and a residents guide that help residents and their representatives to choose where they want to live and to choose a home that will meet their needs, aspirations and expectations. This needs to be tailored to the abilities of the individuals who may wish to come and live at the home. There have been no recent admissions to the home. The senior support worker advised that two new admissions are being considered for House 56 in 2007 and that these residents had been visiting the home to meet staff and look at the accommodation. The current resident in House 58 has lived there for many years; old assessments prior to admission were not on the current file. The current needs of the resident are regularly assessed, including personal choices and healthcare needs. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 9 The resident does have a contract, this details services, fees and accommodation and was signed on behalf of the resident by an advocate. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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): Standards 6,7 and 9. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the ability to plan and implement the care of the resident whilst promoting personal choices. It has effectively identified risks and has management plans in place to help reduce harm to the resident and other people. EVIDENCE: The resident has good care plans that have been written clearly and concisely. They record how the resident wishes to be assisted and how the resident wishes to be treated. The care plans address the needs, personal choices and abilities of the resident identified in the assessments. They cover many areas including health care, personal care, communication and mobility and record personal choices such as “I can walk unaided and I don’t wear shoes or slippers in the house”. All assessments and care plans describe what the resident wants, they include many likes and dislikes such as meals and activities and have been incorporated into the care plans and where needed within risk assessments. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 11 The resident has had support from an advocate who has helped the resident with signing the contract, finding a new GP and enabling the psychiatrist to know the resident better. Risk assessments are available they are well written, clear and concise and contain a management plan to help reduce risk. These risk assessments are reviewed every six months or when there is a changing need or incident. The risk assessment review does not indicate if the measures taken have been effective or otherwise. Examples of the risk assessments are reducing self injurious behaviour and reducing dangers with domestic tasks such as using the laundry and the kitchen. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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): Standards 12,13,15,16 and 17. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has the ability to support the resident to make choices about preferred lifestyles. These choices are fully considered within the risk assessment process and where risks can be managed support is given. Although choices are not always safe or healthy the resident choices are not disregarded EVIDENCE: The home have assessed the lifestyle needs of the resident and considered through the risk assessment process many health and safety issues. The resident is supported to develop domestic skills in the laundry and kitchen through a process of learning. The resident has been enabled to continue interests including photography and arts and crafts, and risk assessments are in place to ensure this is safely conducted. The resident normally takes part in these activities alone in the Snoezelen room. There is no formal programme of education, occupation, social contact and relationships. There is a care plan in place that describes the daily routine of the resident, which includes many Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 13 personal choices such as routine on waking, personal hygiene, meals and going to bed. The resident has a social diary, which records visitors mainly received at the home. The resident has a book of pictures, which help with communicating choices and preferences such as with meal planning. The senior support staff will often make a record of choices made by the resident on a format known as “talk time”, this records requests made by the resident, such as items wanted from the shop. Meals are planned once a week with the resident, and include many of the choices of the resident. It is recognised that these choices are not always healthy and a care plan has been developed to promote a healthier diet. Health issues are being closely monitored. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the ability to support the resident to access routine and as required personal and healthcare support. This is well planned and promotes the health and well being of the resident. EVIDENCE: The resident has care plans and risk assessments about the support needed with personal care and it includes the choices, strengths and abilities of the resident. The care plans describe the routine staff follow, such as putting clothes out, preparing the bathroom, running the bath and giving lots of time. Toiletries and clothing are kept away from the resident; they are stored in the staff sleeping-in room due to apparent risks. Alternative safe storage needs to be made. Records maintained by the home reflect that a psychologist and a psychiatrist regularly review the healthcare of the resident. The advocate has arranged for the resident to receive a GP service and other records reflect the resident has opportunity to see chiropody, dentist and optician, however at times the resident will refuse some of these appointments. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 15 The home uses a High St chemist to dispense medicines prescribed by the GP. The staff order, store, administer and dispose of all medicines. Records are well maintained and there is a protocol for the administration of some medicines, which are to be given as needed to the resident. Storage is safe and weekly audits of stock are undertaken. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the processes and systems for the resident and their representatives to make and have complaints managed and for the resident to be protected from abuse, this will ensure improvements and the safety of the resident. EVIDENCE: The advocate returned a survey form and had no complaints to make about the service. The senior support worker advised that no complaints had been made, however no log of complaints blank or otherwise was available for inspection. There is a complaints policy with a form to track complaints received, there were no entries on this form. The Commission has not received any complaints in the past 12 months. The Adult Protection policy was seen and a copy of local multi agency guidelines were available at the home, the staff on duty were aware of their responsibilities to protect the resident and all new staff as part of the induction are required to read the policy and guidelines. The policy appears good to guide staff in their responsibilities and to ensure concerns about protection are reported without delay. The home does support the resident to manage some money and provides a safekeeping facility; risk assessments are in place about personal finances. The systems and records are good and ensure it is safely managed. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 17 Records of staff training faxed to the Commission post inspection reflect that some staff have undertaken training in Adult Protection. Further training has been arranged for the 30th November 2006. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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): Standards 24, 26, 27, 28 and 30. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has not adequately demonstrated it has the ability to provide the resident with a suitable environment, in areas it lacks storage, safety and repairs are outstanding. This may put at risk the health and safety of the resident and staff. EVIDENCE: A requirement of the last inspection to undertake a programme of internal and external repair and refurbishment had only been partially met. Communal areas of houses 56 and 58 were seen. Outside house 56 the brick wall has many bricks missing, this has been a concern at previous inspections and has not been repaired. House 56 has recently been refurbished for the accommodation by two new residents in 2007. No residents are currently resident in house 56. In the kitchen of house 56 there is an older style kitchen, which in the main is fit for purpose, however some of the draws have collapsed and are in need of repair. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 19 Throughout both of the houses furniture and fittings do appear to be fit for their purpose. However storage of many of the residents belongings in house 58 (clothes and toiletries) are in the staff sleeping-in bedroom, it is recognised that the resident must not access them without staff in attendance, however they are not secure and alternative storage must be sought. House 58 has an old carpet that is in adequate condition yet old, it is of a very busy design and this does create some problems. (see standard 42). The facilities for staff who are on sleeping in duty are poor, they use a bedroom closest to the resident bedroom, there is only a wash hand basin in the sleeping in room for them to attend to their own personal hygiene. The senior support staff may be on duty for upto 24 hours. There are good arrangements for control of infection, the laundry is outside in house 58 and on the first floor in house 56, there are clinical waste facilities and a washing machine with a sluice cycle available, and staff do not need to pass food storage and preparation areas to access the laundry. In respect of house 58 the bathroom used by the resident has areas of damp on the wall, which must be addressed and there are areas in the snoezelen room where wall paper has been damaged. The dining area needs some attention and the linoleum where damaged in the kitchen must be repaired or replaced. Both houses have bathrooms that are adequate for residents without mobility needs as these are domestic step in baths with an electric overhead shower. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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): Standards 32, 33, 34 and 35. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the ability to provide the resident with good numbers of staff, who are safely recruited and who are trained. Some gaps in training may put the resident and other staff at risk. EVIDENCE: Some staff records could not be fully accessed at the time of inspection, as the manager was not on duty. Since the inspection the manager has provided required records. The staffing rotas available at the visit and included with the pre inspection questionnaire indicate that there are appropriate levels of staff on duty to meet the needs of the resident who lives in House 58. During day hours there are always two staff on duty 9am to 9pm, and one sleeping in between 10pm and 9am, all staff are senior support workers or the manager. Staff training records were faxed to the commission for all permanent staff, post inspection. It was evident that staff are receiving training, yet there are gaps in some safe working practices including fire safety and manual handling. Staff are being trained and have been trained to meet the specific needs of the resident for example Learning Disabilities Award Framework, promoting Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 21 empowerment, autistic spectrum disorders and safe handling of medication. The records did not make reference to National Vocational Qualifications, however the pre inspection questionnaire indicated that at present 66 of staff have completed the award at level two or above. Since the inspection visit the manager has advised that the Commission were not provided with all training records and has recorded that internal 6 monthly fire training does takes place. Records regarding staff recruitment were also faxed to the Commission post inspection for two current members of staff, one being the most recently recruited senior support worker. Both records had evidence that at least two written references and a Criminal Records Bureau disclosure had been sought prior to appointment and that a health screening had been completed and both records had required documents to confirm their identity. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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): Standards 37, 39 and 42. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has not demonstrated its ability to be effectively managed in all required areas, there are gaps in health and safety that put resident and staff at risk and which may harm their health and welfare. EVIDENCE: As recorded the manager was not on duty at the time of inspection. The survey letter returned to the Commission completed by the residents advocate indicated that she had been given all support from the manager and staff to access required information and to carry out her role as the an independent advocate. Staff on duty referred to the manager positively and in discussions with the inspector were complimentary of her abilities, no issues or concerns about her competencies were disclosed. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 23 The home does have a Quality Assurance system and policy in place. The most recent quality audit was completed on the 11/09/06. There are 12 objectives to be audited, examples of these are as follows Health and Safety regulations are observed, service users specialist needs are identified and met and service users are provided with healthy, nutritious and enjoyable meals. The audit states whether the objective has been achieved or not. Where it has not recommendations have been made. This is good practice. The system forms its own report, improvements are needed so that residents can understand the pertinent points of the report being outcomes and also that the improvements needed are in the form of an action plan with timescales of when it will be achieved. Some areas of Health and safety in the home are generally well managed including tests, service and repair to equipment, premises and utilities. The fire officer asked for an emergency light to be considered on the staircase of the houses, at the time of inspection the inspector tripped at the top of the stairs in house 56, dangerously close to the top of the stairs. At the top of stairs it is difficult to see other steps, there are no mind the step signs and the carpet colours do not help recognition of other steps. There are therefore more concerns that this may impede safe evacuation in a smoke filled environment. There are risk assessments in place, for fire safety, health and safety and staff safety. These are regularly reviewed. The fire system and equipment are routinely tested and serviced. The gas equipment and installation are certified as safe. The electric has a current safety certificate for installation, and all electrical appliances have been tested. There was concern at the inspection that some of the appliances being tumble dryer and washing machine had failed the test yet were still in operation. The senior support worker in charge at the time of inspection put signs on the equipment declaring they should not be used. The manager has since advised that the plugs have been removed and alternative tumble drying facilities, being next door in House 56 are being used and that until the dishwasher is repaired staff will hand wash in the kitchen. Since the inspection the manager has advised that the above mentioned electrical items have been retested by the same company, this company have acknowledged that the testing machine was incorrectly set for these appliances and they have since passed the safety test. The environmental health officer last visited the home in February 2004, and had no concerns about safety in the kitchen and food management. The lid of the fridge freezer is loose and may not maintain the required temperature control of food. There were areas of the kitchen that were not clean including the oven and the over hob extraction unit. There are records of accidents and incidents maintained at the home, detailing where injury usually minor had been sustained by the resident, of the three completed in 2006 one had been notified to the Commission under Regulation Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 24 37. There are risk assessments in place for the resident about self-injurious behaviours and they are monitored through behavioural management plans in consultation with the psychologist. Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. 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(1a-f) 5(2-3) Requirement The manager must produce a service user guide in a suitable format for each service user, which shall include all matters listed in the Regulations. On completion a copy of this information must be submitted to the CSCI and each service user or their representative as appropriate. The registered person must ensure that when risk assessments are reviewed that they include a statement of whether the measures taken have been effective or not in reducing risks. The registered manager must ensure that a record of complaints is available at the home. A programme of repair and redecoration must be undertaken internally and externally to ensure the premises are safe and comfortable for service users. Partially completed, Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 27 Timescale for action 31/12/06 2 YA9 13(4)(a-c) 12(1) 31/12/06 3 YA22 17(2) Schedule 4(11) 13(4a-c) 23(2 b) 30/11/06 4 YA24 31/12/06 requirement of to be completed by 01/08/06 not met, this requirement is carried forward. This programme must include improvements identified in the Environmental standards (24 to 30) of this report. 13(6) The registered person must 12(4)(a) make alternative arrangements in the best interests of the resident to have personal belongings stored in a safer area. 23(3)(a) The registered person must 16(2)(j) ensure that staff who work sleeping-in duty are provided with adequate facilities to maintain their personal hygiene. Shower or bathing facilities must be considered. 18(1)(c)(i) The registered person must ensure that all staff are kept upto date and receive safe working practice training including moving and handling. 13(4)(a) The registered person must 23(4)(b) ensure safety on the stairs of both houses, including adequate lighting in emergencies and that the steps at the top of the stairs can be clearly seen. 16(2)(j) The registered person must ensure that food safety is improved, this must include repairing the broken lid on the freezer and ensuring the hob and extraction unit in the kitchen are kept clean. 37 The registered person must ensure that accidents in the home that affect the well being of the resident or where the resident has an injury are reported to the Commission. 5 YA26 30/11/06 6 YA28 31/01/07 7 YA35 31/12/06 8 YA42 31/12/06 9 YA42 30/11/06 10 YA42 30/11/06 Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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 Refer to Standard YA24 YA39 Good Practice Recommendations It is recommended the garden be further developed with new service users. Not assessed and is carried forward It is recommended that quality assurance system provide a report in a format that maybe understood by the resident and include a timescale for the recommendations of the report to be improved upon. It is recommended that the accident policy be reviewed to include action to be taken in event of an incident, and reporting the accident to the CSCI. Not assessed and is carried forward It is recommended that the missing persons policy be further developed to include a well person check on the service users return, direction to call those parties alerted to stand down, and to notify the CSCI. Not assessed and is carried forward. 3 YA41 4 YA41 Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Gravelly Hill, 56-58 DS0000065009.V314669.R01.S.doc Version 5.2 Page 30 - 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. 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