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Inspection on 27/10/05 for 29 Greenhill Road (westholme)

Also see our care home review for 29 Greenhill Road (westholme) for more information

This inspection was carried out on 27th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 78 statutory requirements (actions the home must comply with) as a result of this inspection.

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 plan of care for one person who lives on Hilltop was assessed. This was very individual, and showed they had been involved in writing the plan. Service users on both Westholme and Hilltop are supported to stay in touch with their family and friends. This can be in person, by telephone or letter. Staff are friendly, and they were all observed to be pleasant and helpful as far as possible. One person who lives on Hilltop said the home was a good place to live. Things they particularly liked were their new room, the new kitchen, and being able to go out whenever they wanted.

What has improved since the last inspection?

TRACS has reduced the number of people that live at 29 Greenhill Road, and undertaken lots of building work to make the home a nicer place to live. This work is still ongoing, but the accommodation available at the home is improving. Since the last inspection seven bedrooms have been provided with ensuite, a new kitchen has been fitted, smoke room provided, and a new laundry room developed. Work to level out uneven slabs in the garden had been undertaken. Fire safety checks had been undertaken and recorded as is required. Most repairs identified at the last inspection had been undertaken.

What the care home could do better:

This inspection identified numerous serious concerns, and the home is required to get better in most areas inspected to ensure service users needs are met. The CSCI has previously raised concerns about the management of the home. Since raising these concerns the CSCI is aware TRACS has tried to recruit a manager and placed a senior member of staff in the home. This remains inadequate. The post of home manager must be recruited to, and in the interim TRACS must address the management shortfalls. TRACS must make sure that appropriate plans are made to keep service users safe when work is undertaken on the home. At the time of inspection two lounge rooms were closed, and the decorators were painting in all areas of the home. The majority of service users were at home during the day, this resulted in some people becoming distressed, and in them getting paint on their clothes and body. One person who lives in the home felt very strongly that work shouldn`t be going on around them like this. Two service users said the home was very noisy and busy, and that they didn`t like it. Inspectors were also concerned about this, and identified in some preadmission documents people had said they didn`t like busy places or loud noises. TRACS must get better at fully assessing the people they admit to the home, and using the trial visits to establish risks service users may present to each other. People admitted to the home must have plans of care, and risk assessments in place. Staff, some service users and the inspectors identified that more interesting activities must be provided for people. Two people that live on Westholme had been recorded as "Walking around the home and garden" on most of the day`s inspectors sampled.An Adult Protection investigation has been undertaken. This identified a delay in staff making the management aware of the allegation. No refresher training to ensure staff are aware of the procedure has been undertaken. Some of the people have changing needs. Staff had not kept care plans, and risk assessments up to date regarding these needs. People had been involved in setting goals in their review meetings. It was not always clear how these were being worked towards, or if they had been achieved. The records held in the home were in a muddle. Examples of this are the staff training records, and records of accidents and incidents that were not stored in order, securely, or in an auditable style. The records of accidents and incidents identified numerous incidents that had not been reported to the CSCI as is required. The people who live in the home had not been supported to keep their rooms tidy. During the inspection empty cups, medicine tots, dirty bedding and dirty laundry were all observed in bedrooms. Clean laundry waiting to be put away was also evident. Many of the rooms had not been well finished after building or decoration, with examples of beds with no head boards, a toilet with no toilet seat, no towel rails or mirrors in many ensuites being observed. The inspectors could not establish that enough staff were employed. Risk assessments for people who live in the home show three people need one to one staffing all the time. The minimum number of staff on duty is five. These five staff also had to cover breaks on both Westholme and Hilltop. The staff also have to cook, and undertake laundry duties. The staff at Westholme has changed significantly on two occasions in the last year. Many staff are new or inexperienced. Staff retention must get better. TRACS informed the CSCI in their action plan of work they have planned or undertaken to address this. The kitchen was not clean or in good order. Dry food goods had not all been stored safely, frozen foods had not all been wrapped or dated. The food cupboards were dirty. Health and Safety was not well managed. Significant changes had occurred within the building. Risk assessments for this had not been reviewed, to reflect these changes. Routine tests of equipment had not been all undertaken as required.

CARE HOME ADULTS 18-65 Greenhill Road, 29 (Westholme) Moseley Birmingham West Midlands B14 9SS Lead Inspector Alison Ridge Unannounced Inspection 27th October 2005 08:10 Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greenhill Road, 29 (Westholme) Address Moseley Birmingham West Midlands B14 9SS 0121 449 6383 0121 449 6573 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) TRACS Vacant Care Home 14 Category(ies) of Learning disability (14), Physical disability (14) registration, with number of places Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years. 14 people requiring care for reasons of learning disability or acquired brain injury (14 LD, PD). 13th June 2005 Date of last inspection Brief Description of the Service: 29 Greenhill Road comprises of two units, TRACS Westholme, and TRACS Hilltop. TRACS Westholme is registered to accommodate ten people under the age of 65, who have a Learning Disability or Acquired Brain injury. Three of the rooms within the accommodation on the ground floor have been adapted to support people with impaired mobility. The remaining bedrooms are on the first floor, and full mobility is required to access these rooms. This part of the home has a communal lounge, dining room, smoke room, kitchen, and bathrooms and toilets on both floors. TRACS Hilltop occupies the second floor of the home. Hilltop provides care and support for four service users working towards more independent living, offering people the opportunity to develop skills such as budgeting, cooking, home making, and taking greater responsibility for planning their lifestyle. This area of the home has a separate staff team, and its own facilities such as a lounge, kitchen, laundry and bathroom. The home has a large, mature garden at the rear. The home has transport, and is located close to local bus routes. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced inspection. They were in the home for over ten hours. Information used in this report was collected by talking to the people that live in the home, and by observing the way they were cared for and supported. Inspectors spoke with six members of staff, and the acting home manager. Records about care, staffing and health and safety were inspected. A tour of the building was undertaken. Inspectors were concerned about the findings of the inspection, and the large number of previously made unmet requirements. Inspectors met with the service manager and Responsible Individual the week after the inspection. At this time TRACS provided an action plan detailing how the issues raised had been, or would be addressed. It is the inspector’s intention to make further visits to the home, in addition to the two statutory visits already undertaken. Since the last inspection an Adult Protection investigation has been undertaken. TRACS co-operated fully with the investigation. A complaint was received about the home. The complainant alleged that inadequate staff were on duty, an ensuite shower was broken, and that one service user had fallen down the stairs. The inspector confirmed adequate numbers of staff were provided, all other elements of the complaint were upheld or partly upheld. Inspectors extend their thanks to service users and staff that assisted with this inspection. What the service does well: The plan of care for one person who lives on Hilltop was assessed. This was very individual, and showed they had been involved in writing the plan. Service users on both Westholme and Hilltop are supported to stay in touch with their family and friends. This can be in person, by telephone or letter. Staff are friendly, and they were all observed to be pleasant and helpful as far as possible. One person who lives on Hilltop said the home was a good place to live. Things they particularly liked were their new room, the new kitchen, and being able to go out whenever they wanted. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: This inspection identified numerous serious concerns, and the home is required to get better in most areas inspected to ensure service users needs are met. The CSCI has previously raised concerns about the management of the home. Since raising these concerns the CSCI is aware TRACS has tried to recruit a manager and placed a senior member of staff in the home. This remains inadequate. The post of home manager must be recruited to, and in the interim TRACS must address the management shortfalls. TRACS must make sure that appropriate plans are made to keep service users safe when work is undertaken on the home. At the time of inspection two lounge rooms were closed, and the decorators were painting in all areas of the home. The majority of service users were at home during the day, this resulted in some people becoming distressed, and in them getting paint on their clothes and body. One person who lives in the home felt very strongly that work shouldn’t be going on around them like this. Two service users said the home was very noisy and busy, and that they didn‘t like it. Inspectors were also concerned about this, and identified in some preadmission documents people had said they didn’t like busy places or loud noises. TRACS must get better at fully assessing the people they admit to the home, and using the trial visits to establish risks service users may present to each other. People admitted to the home must have plans of care, and risk assessments in place. Staff, some service users and the inspectors identified that more interesting activities must be provided for people. Two people that live on Westholme had been recorded as “Walking around the home and garden” on most of the day’s inspectors sampled. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 7 An Adult Protection investigation has been undertaken. This identified a delay in staff making the management aware of the allegation. No refresher training to ensure staff are aware of the procedure has been undertaken. Some of the people have changing needs. Staff had not kept care plans, and risk assessments up to date regarding these needs. People had been involved in setting goals in their review meetings. It was not always clear how these were being worked towards, or if they had been achieved. The records held in the home were in a muddle. Examples of this are the staff training records, and records of accidents and incidents that were not stored in order, securely, or in an auditable style. The records of accidents and incidents identified numerous incidents that had not been reported to the CSCI as is required. The people who live in the home had not been supported to keep their rooms tidy. During the inspection empty cups, medicine tots, dirty bedding and dirty laundry were all observed in bedrooms. Clean laundry waiting to be put away was also evident. Many of the rooms had not been well finished after building or decoration, with examples of beds with no head boards, a toilet with no toilet seat, no towel rails or mirrors in many ensuites being observed. The inspectors could not establish that enough staff were employed. Risk assessments for people who live in the home show three people need one to one staffing all the time. The minimum number of staff on duty is five. These five staff also had to cover breaks on both Westholme and Hilltop. The staff also have to cook, and undertake laundry duties. The staff at Westholme has changed significantly on two occasions in the last year. Many staff are new or inexperienced. Staff retention must get better. TRACS informed the CSCI in their action plan of work they have planned or undertaken to address this. The kitchen was not clean or in good order. Dry food goods had not all been stored safely, frozen foods had not all been wrapped or dated. The food cupboards were dirty. Health and Safety was not well managed. Significant changes had occurred within the building. Risk assessments for this had not been reviewed, to reflect these changes. Routine tests of equipment had not been all undertaken as required. Please contact the provider for advice of actions taken in response to this inspection. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 8 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 9 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 Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 10 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): 2, 3, 4, 5 TRACS undertakes pre-admission assessments and offers trial visits. These are not being undertaken adequately to ensure prospective service users needs could be met by the home, and that service users will be able to live safely together. TRACS issues a robust contract. These had not been signed by TRACS or the service user, therefore it could not be established service users are aware of the terms and conditions of their placement. EVIDENCE: The work undertaken with one service user, who recently moved into the home was assessed. Records showed that an assessment was undertaken, and that visits to the home, to “test drive” it were provided. The assessment record did not evidence that all areas had been assessed, for example mobility was not assessed, as the service user was in bed at the time of the assessment visit. There was no evidence that this had been returned to and assessed. Likes, dislikes and needs had been identified in the assessment. It was not apparent that the care plan or care delivery (subsequent to the service user moving in to the home) had been arranged to accommodate these. An example of one person needing a systematic plan of care for their care Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 11 routines, and that they disliked loud noise were identified in the assessment but did not feature in the plan of care. One pre-admission assessment identified that a potential service user was at risk of absconding. Work undertaken by staff (subsequent to him moving in to the home) was inadequate, and had resulted in the service user leaving the premises without support on several occasions. The acting home manager does not undertake the pre-admission assessment. In a comment sheet attached to the assessment he had stated,” The service users placement will be an interesting learning curve for Westholme”. This is not confirming that the he feels the home and staff team can meet the service users needs. No evidence of how the learning curve was to be addressed was available. Inspectors found the mix of service users needs accommodated at present to be diverse, and that service users had known behaviours or needs that act as triggers for other service users. It was not evident that best use was being made of trial visits to explore these prior to people being admitted to the home. Staff and the acting manager also raised concern regarding the mix of needs the service users accommodated display, and how these can be met within the same service. The inspectors raised concern at the timing of two recent admissions, which followed very close to each other, and within days of the acting manager going on planned annual leave. The combination of this, and the ongoing development works in the home caused the inspectors serious concerns. TRACS informed the CSCI additional support was provided to the home over this period by the area director. The service users and their placing authorities were made aware of the condition of building works in the home prior to admission. Service users files all contained a written contract, detailing the terms and conditions of their stay, and the costs. Not all these documents had been signed by either the provider or the service user. For service users who have resided at the home for a while, details of the current fees charged must be updated. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Care documents and risk assessments do not fully or accurately underpin service users needs or the risks they face. Service users are consulted on how they wish care and support to be provided. Records and staff handovers must improve to ensure confidentiality is maintained. EVIDENCE: Six plans of care were sampled either in full or part. Each service user had an individual plan of care. For service users that had most recently moved into the home (eight weeks prior to inspection) these were very much in draft form, and did not give staff clear guidance on the persons needs and how they were to be met. The plan of one service user on Hilltop was assessed. This was very personalised, and showed evidence of the individual being involved in the drafting and development of the plan. Hilltop aims to support people to move towards greater independence. The plan did detail how the person was being supported to obtain greater Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 13 household and self-help skills, but did not show any of the bigger picture, life plans for this person. The care plan detailed goals, including, joining a social club, and going to a local leisure centre. Evidence of who was helping the person work towards these goals, and of the progress made were not available. The service user tracked on Hilltop, accesses the community without staff support. It has previously been identified that this requires risk assessing. This remains outstanding. Plans of care for established service users in Westholme were detailed, but did not evidence that they had been reviewed or amended as needs change. One service user had experienced a significant change in needs, and the plan did not reflect this at all. Some risk assessments for service users accommodated on Westholme had not been reviewed within the timescale set by the author. Of even greater concern was the number of incidents and accidents recorded, which had not prompted staff to review the risk assessment, to ensure control measures remain appropriate and adequate. Effective reviews had not always been undertaken, with the reviewer writing, ”No change”, a signature and date, but with no evidence given of how the review was undertaken, or the information considered to reach that conclusion. Some care documents had identified significant risks, yet no control measures or plans to reduce these were in place. One risk assessment tracked recorded that the person was at, “Risk of serious harm to self and others.” No further work or documentation to underpin this was available. Plans of care were stored securely. Inspectors were concerned about storage of other records, including accident records. These were not secure or in good order, and could result in confidentiality being breached. The staff interactions with service users were positive. The morning planning session was not undertaken confidentially due to space limitations. This resulted in service users needs and plans being discussed in front of other service users. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 14 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): 11, 12, 13, 14, 15 Service users on Westholme are not offered opportunity to undertake interesting and varied activities of their choice, on a regular basis. Service users on Hilltop have greater opportunity to undertake activities of their choosing, and reported being satisfied with this. Service users are supported to stay in touch with their family and friends. EVIDENCE: The opportunities for service users to undertake interesting and varied activities in the community and at home were tracked. The records for one service user identified very limited opportunities. In the twenty-six days tracked two structured activities were recorded. All other records detailed,” Walked around house and garden” or “paced around” or “wandered around most of the day”. It was not evident that any structured activity or diversions were offered to the person. Another service user tracked had undertaken similar limited activities, with these being mainly targeted at walking around the home and gardens. In the same service users care plans activities, which they, or staff at a care review had identified an interest in, were recorded. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 15 Evidence of these being provided or offered was not available. In one instance the inspectors raised concern that the activities would remain appropriate, due to the persons changing needs. Risk assessments to underpin community activities and access were tracked. These were overdue for a review, and had not been reviewed in light of changing needs and incidents. The documents did not detail the current situation, or give relevant information and control measures. Staff at the home had organised a day trip in the week of inspection. Service users who were able, and staff who had supported the trip reported that it was a very difficult day, due to the number of service users, distance to be travelled, and range of individual needs. It was not apparent that this had been well planned or risk assessed prior to the event. One service user on Hilltop spoke with the inspectors about opportunities available to him. The person was able to go out without support, and was happy with the range and frequency of opportunities available to him. Opportunities for service users to stay in contact with their family and friends were tracked. These were generally good, with people being supported to write letters, make phone calls, and undertake personal visits as far as possible. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Personal care was delivered to a good standard. The quality of plans to underpin this varied, and were not always adequate to ensure needs are consistently met in the way service users prefer. Service users healthcare needs had not been well or consistently met. Medication audits did not evidence that all medication had been given as prescribed. EVIDENCE: Service users plans generally contain detailed morning and evening programmes. These enable staff to consistently support service users in the way they prefer. It was of concern that one recently admitted service user, had no clear plan of care regarding meeting personal hygiene, and that this had been identified prior to admission as a specific need. Inspectors raised concern (that was supported by the acting manager and staff on duty) that the ground floor bathroom, is not of an adequate size to safely support service users to undertake their personal care. In the early morning some service users had come downstairs in their nightwear. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 17 Concern was raised by inspectors regarding safety, as some pyjama legs were unduly long, and could present a trip hazard, and the quality of one pair were very worn. One service user had no slippers or shoes on, which was of concern regarding the amount of decorating and building debris around. Service users who are at risk of self-neglect, and who may choose not to get up, or to undertake personal care were tracked. Clear guidance on how to support the person, and when to request assistance from other members of the multi-disciplinary team were not available. The personal care matrix had not been completed consistently. For one-person gaps of up to five days were noted between personal care being delivered. This has previously been identified as requiring review. Inspectors raised serious concerns at the way in which health care needs were being met. There was no evidence that service users had been supported to undertake all routine healthcare screening, with the required frequency. In one-service users file a note identified a dentists appointment was due in January 2005. No record of an appointment being attended or offered was available. It was not evident that service users weight was being taken monthly as planned, or that opportunity to be weighed was being made available. In one pre-admission assessment it was identified referral was required to members of the multi-disciplinary team if the admission went ahead. No evidence that the referrals had been made in the eight weeks of the placement was available. Records of significant events were also patchy. One service users ill health and resulting admission into hospital was tracked. Records made were incomplete. Some service users accommodated have some difficult to manage behaviour. At the time of the inspection extensive building and re-decoration works were being undertaken. No evidence that the implication of this work on service users needs was available. At the time of inspection incidents and near misses were observed that were directly related to the noise, lack of communal space, and chaos in the home. Daily records for one person identified that in twenty-six days, seven incidents of verbal aggression, or threats of physical harm had been made. No reactive management plan, or detailed reporting or analysis of these incidents had been undertaken. Risk assessments for this person identified there is, ”No perceived risk to other service users”. Inspectors were concerned that the practice and documentation around this persons needs were not adequate to underpin their needs, or ensure the safety of others. One service user was observed to have very repetitive behaviour that has previously been observed to put him at risk of harm. Staff practice regarding distracting or diverting the situation was poor, and not delivered as planned when tracked at previous inspections. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 18 It was not evident that all issues identified in service users pre-admission assessments had been fully explored. One-service users assessment identified he experienced ongoing pain, particularly when walking. No plan of care regarding pain management was available, and walking was the primary activity being undertaken by the individual. Records of appointments being attended had been made. These were not all clearly documented to enable tracking to be undertaken. An example read included, ”Hospital appointment-no changes required.” The inspector tracked the support given to one service user who had complained of back pain. This persisted over several days, and resulted in a GP appointment being made. In the days sampled one record of pain relief being offered or given was found. It was not evident this service user had been offered the pain relief prescribed. Some service users accommodated have changing needs. It was not evident that care records were amended in light of changes. One service user was found to have very specific night time care needs, which often resulted in him sleeping on a sofa. Evidence as to how this had been planned for, or the strategy to support/encourage the person in to their bed was not available. Inspectors were very concerned for the welfare of one service user tracked, this was supported by the acting manager, who informed inspectors the home were struggling to meet this persons needs. Evidence that this had been brought to the attention of the placing authority for review or discussion was not available. The needs of one service user with epilepsy were tracked. No plan of care to address this area of need, and to ensure staff have the required knowledge and information to safely meet this need was available. Medicine management was assessed on Hilltop and found to be generally in good order. Current copies of prescriptions could not be located. One non-blister packed medicine had two tablets in excess of that recorded. One opened tube of cream required discarding. (Opened 28/8/05) Medicine on Westholme was of serious concern. Omissions were noted on the Medicine Administration Record (MAR) It was not evident these had been followed up with the staff responsible. One prescribed medicine had changed dose part way through the medicine cycle. Staff had not clearly recorded when the change had occurred, and auditing of tablets dispensed and given was not possible. Staff must discontinue medications, and re-write the new dose in the event of a change occurring. One service user had experienced an unsettled night, and displayed some difficult behaviour. As required medication had not been given. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 19 Protocols for as required medicines require further development. Protocols must clearly state when a medicine to be used, the rationale for administering one or two tablets, and how to identify if the medicine is required. The protocol must be kept under review. Three non-blister packed medicines were audited. None of the medicines tallied with record of receipt and administration. Evidence that staff had undertaken medicine audits were not available. The medicine fridge temperature had not been taken regularly. Staff reported it did not maintain an even temperature. It has been required this be repaired or replaced. Medication storage on Westholme was inadequate. The amount of medicine held exceeded the secure medicine storage available. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users were not being protected from risks other service users present to them. TRACS was not running the home in such a way that ensured the safety and welfare of the people accommodated. CSCI has received and investigated one compliant regarding this home. EVIDENCE: The CSCI received a complaint about the home in October 2005. The complaint had three elements, 1. A broken ensuite shower. 2. Inadequate numbers of staff on duty 3. Specific concern about the night care needs of one service user. The inspector found adequate numbers of staff on duty, but all other elements of the complaint have been upheld or partly upheld. An allegation of an Adult Protection nature has been made about the home in August 2005. West Midlands police and TRACS jointly investigated this. It was upheld that an incident had occurred. The police concluded this was not of a criminal nature and action to address this was undertaken by TRACS. This was undertaken robustly to the satisfaction of all organisations involved. The work undertaken by the home in light of the allegation was tracked at the inspection. It was not evident that refresher training had been undertaken to ensure staff are aware of the reporting procedure in event of an allegation being made. Inspectors raised serious concerns with TRACS about the running of the home, and the way in which risks service users present to each other are being managed. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 21 Significant work is required in both of these areas. TRACS informed the CSCI that they have undertaken significant work to address this matter and will go on to do so. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 Work to improve the structure and fabric of the premises is being undertaken. Serious issues regarding safety, cleanliness, and adapted facilities were identified. EVIDENCE: Extensive development work of the premises has been undertaken in the past year. This work is very much ongoing. Inspectors anticipate that this will greatly improve the premises when complete, and work undertaken to date, has resulted in service users having much better bedroom space, and a high number of rooms, also having ensuite facilities. Inspectors did not find that service users safety and welfare had been safeguarded adequately. At the time of inspection concern was raised regarding COSHH products left unsupervised, ladders left around the interior of the home, incidents that had resulted in service users leaving the home without staff support, (as doors and gates had been left unlocked), and decorators painting throughout the home, leaving no signage, or indication of wet paint, resulting in service users, and inspectors getting paint on their clothes and body. The decoration had resulted in both the lounge, and smoke room being taken out of use. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 23 Service users were using the dining area, to both eat and relax. The space available was inadequate for the number of service users and staff. Service users TV in this room had a very poor picture. Smokers used the room, and no non-smoking communal space was available. The inspector was pleased to be shown some of the newly developed bedrooms, and extends her thanks to service users for facilitating this. The rooms were much larger than previously, and a large number also have new ensuite facilities. Rooms had not been finished to a high standard, and items such as towels rails, mirrors and, headboards had not been provided or fitted. Bedrooms had been left in an untidy state. Several beds required changing. Some of the bed linen was excessively worn, dirty laundry had not all been collected, and clean linen required putting away. Bathroom facilities continue to require development. Facilities on both the first and second floor required upgrading. The ground floor assisted bathroom has been upgraded. The arrangement of fittings in the room does not facilitate staff to safely support service users, or for staff to exit the room in the event of a challenging incident. One-service users walking aid was identified as being bent on the left hand side. An appointment for the maintenance of this equipment must be made. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 24 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): 32, 33, 34, 35, 36 Staff demonstrate positive regard for the service users they support. Adequate numbers of trained and supervised staff are not provided. Recruitment practice does not ensure service users are protected. EVIDENCE: The inspectors interviewed six staff. All staff demonstrated a positive regard for the service users they support, and most evidenced their knowledge of the service users support needs, and current issues. Staff practice during the day was generally positive, and staff had many additional factors to work around. Inspectors extend their thanks to staff for their support with the inspection process. The recruitment records of five staff were assessed. In all files the required documents were available. It was not evident how shortfalls in the application had been explored with the candidate, prior to an offer of employment being made. Examples such as incomplete work history’s, and concerns raised by referees were noted. One candidate had applied for, and been accepted for employment ten months prior to commencing work. It was not apparent any review of this period was undertaken prior to commencing work. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 25 Inspectors raised concern at the number of staff on duty. At present the homes risk assessment identifies a minimum of six staff are required to cover both Westholme and Hilltop. The assessment identifies three service users require one-to-one support in Westholme, and that one of the staff is to cover Hilltop. The remaining two staff are required to support seven service users, and undertake a full range of multi-role tasks including laundry and cooking. Most staff work long days, which results in them each taking a one-hour break during the day. Work planners identify that sometimes staff “double up” on breaks, reducing the number of staff working by two, and that staff from Westholme are required to cover Hilltop staff breaks. Inspectors have previously visited the home in the early morning before day staff arrive on duty. Concern was raised at that visit about the number of service users awake at that time, and requiring support or supervision. This was greater than the staff resources available. Inspectors were informed the Divisional Director undertook a review, but that no change to staff working patterns has resulted. This remains of serious concern. Records of staff training were not auditable. It was not possible to establish from the records presented who had undertaken training, when, the length of the course, or the qualification of the trainer. It was not evident that all training provided would be adequate to train staff to the required standard. Examples of mandatory training, that was provided in house, for duration of one hour was brought to the attention of the acting manager. Records of supervision showed that when undertaken these were to a good standard, but that the frequency of the supervision was inadequate to meet the National Minimum standard of six per year, or to ensure staff are well supported in their job role. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 41, 42 The management arrangements of the home are inadequate and do not ensure positive outcomes for service users. Further more current management arrangements place service users and staff at harm or risk of harm. EVIDENCE: The home operates with an acting manager. This person withdrew from the CSCI fit person process in July 2005. The CSCI required at that time alternative management arrangements be made. This remains unchanged. The senior staff team at the home has been subject to change, with three significant staff changes in the past six months. The structure and stability of the management team urgently required review, and TRACS are required to recruit a competent and qualified manager for this home. The home had on display a current certificate of insurance and registration. Regulation 26 visits are made to the home each month, and records of these forwarded to the CSCI. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 27 Record keeping systems all require urgent review and development. Records, including those of care, and accidents and incidents were not stored securely or in good order. It was not possible to audit these. Accident/incident records identified a large number of incidents that the CSCI had not been notified of under regulation 37 of the Care Homes Regulations. Regular recorded staff meetings have been undertaken. Health and safety was of serious concern at the time of inspection with hazards apparent around the home, and no control measures in place to address them. It was not apparent that the works being undertaken had been subject to realistic or ongoing risk assessment, or again that control measures had been implemented to ensure service users and staff welfare and safety. Risk assessments for the premises were assessed. Significant changes to many of the assessed areas had occurred, including new kitchen and laundry facilities on Hilltop, the moving of the laundry into the main building at Westholme, and the addition of so many ensuite bathrooms. No review or development of the documents to reflect new or changing risks had been undertaken. The homes health and safety audit undertaken in 12/7/04, and reviewed 13/6/05, similarly makes no allowance for the many significant changes in the premises, and new risks the work present. Staff on duty were not certain that the new washing machine was fitted with a sluice facility, or of how to use it. Records of care identified occasions when this facility would have been required, and it would be of concern if soiled washing has not been hygienically washed. TRACS informed the CSCI this cycle had been programmed into the machine, and have made sure all staff are aware of its presence. The laundry room has recently been moved into the internal home premises. A tour of the premises identified the facility had not been fitted with a smoke or heat detector. It was of further concern to later read this had been identified in a fire risk assessment in May 2005 and no action had been undertaken. Full clinical waste bags were observed dumped in the garden. It was required these be stored appropriately and disposed of. The main to one ensuite shower was tested, which resulted in sparks flying from the plug. An immediate requirement that this be explored and made safe was made. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 1 1 1 1 Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 2 1 1 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 2 2 1 1 1 X LIFESTYLES Standard No Score 11 1 12 1 13 1 14 1 15 2 16 X 17 Standard No 31 32 33 34 35 36 Score X 1 1 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Greenhill Road, 29, (westholme) Score 2 1 1 X Standard No 37 38 39 40 41 42 43 Score 1 1 X X 1 1 X DS0000016713.V260963.R01.S.doc Version 5.0 Page 29 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 4(1,2,17,2,1) Requirement Not assessed at this inspection. The Statement of Purpose must be developed as identified in Standard 1 Not assessed at this inspection. The Service Users Guide must be developed as in Standard 1 A full pre-admission assessment must be undertaken prior to offering the service user a place in the home. TRACS must ensure the timing of new admissions into the home does not jeopardise the welfare or safety of service users or staff. TRACS must undertake a review of service users needs to ensure they are able to meet all assessed needs, and that service users are compatible with each other. Trial visits must be used to fully explore the suitability of the potential service user to the home, and existing service users. DS0000016713.V260963.R01.S.doc Timescale for action 01/11/05 2. YA1 5(1,2) 17(2) 4(2) 14(1,a) 01/11/05 3 YA2 01/12/05 4 YA3 14(1,d) 13(4,c) 01/12/05 5 YA3 14(2,a-b) 12(1,a) 01/01/06 6 YA3 14(1,c) 13(6) 01/12/05 Greenhill Road, 29, (westholme) Version 5.0 Page 30 7 8 9. YA5 YA5 YA6 99 99 15(1) 10. YA6 12(1,a) 15(2,b-d) 11 YA6 15(1,a) 12 13 YA19YA6 YA6 YA19 14(2) 15(2,b) 14(2) 14 YA9 13(4,a-c) TRACS and the service user or their representative must sign all contracts. The record of fees charged must be kept up to date. Unmet from the previous two inspections. Service user plans must show how a service users needs in respect of their health and welfare are to be met. Unmet from the previous inspection. Goals must clearly state how they are to be met, who is responsible, and how it will be known if they have been achieved. All service users must have a care plan that details their needs, and wishes and how these are to be met. Service users plans must be reviewed as needs change. TRACS informed the CSCI this had already been requested. TRACS musts request a review of one identified service user, to ensure his needs can continue to be safely met by the home. Unmet from the previous inspection. Risk assessments for clinical risks service users face including falls, choking and pressure injury must be completed. 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/12/05 01/12/05 01/12/05 Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 31 15 YA9 13(4,a-c) Unmet from the previous two inspections. Risks that service users pose to each other due to their complex and sometimes challenging needs must be assessed and control measures explored and implemented. Risks identified during assessment or care practice must be assessed and control measures implemented. Risk assessments must be subject to effective review. The review must show evidence of how the conclusion was reached. Risk assessments must be reviewed at the set intervals (At least six monthly) and sooner if needs change or following a critical incident. Unmet from the previous two inspections. Risk assessments for service users accessing the community to be developed. Unmet from the previous two inspections. The pages of care notes must be secured to ensure they are safe and confidentiality is protected. Staff handovers/shift planning must ensure confidentiality is maintained. A range of interesting and varied activities must be offered to service users. Activities chosen by service users or at reviews must be planned for and offered. 01/12/05 16 YA9 13(4,a-c) 01/12/05 17 YA9 13(4,a-c) 15 01/01/05 18 YA9 13(4,a) 15 01/01/05 19 YA9 12(4,a) 01/12/05 20. YA10 12(4,a) 01/12/05 21 22 23 YA10 YA12 YA14 12(4,a) 16(2,m-n) 16(2,m-n) 01/12/05 01/12/05 01/12/05 Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 32 24 YA9YA14 16(2,m-n) 13(4,b-c) 12(2) 25 YA18 26 YA18 12(2)(4,a) 13(4,b-c) 27 YA18 13(4,c) 12(1,a) 12(1,a) 13(1,b) 28 YA19 Activities must be risk assessed and the identified control measures implemented. Service users plans must detail how service users prefer their personal care needs to be met. Service users must be supported to choose and maintain clothes and footwear in a good condition, and that will not present a hazard to them. Service users who are at risk of self-neglect must have this need underpinned with a plan, and risk assessment. Unmet from the previous two inspections. 01/12/05 01/02/06 01/12/05 01/12/05 01/01/06 29. YA19 12(1,a) 13(1,b) 15 30. YA19 12(1,a-b) The provider must ensure all relevant healthcare monitoring is undertaken. Not assessed at this 01/02/06 inspection. Indicators of service users mental well-being must be included in the service users plan, or clearly signpost the reader to this information where this care is required. 01/01/06 Unmet from the previous two inspections. Weight monitoring must be undertaken consistently, and records developed to show where, the time and date the weight was recorded. Service users with a Learning Disability must be supported to obtain a Health Action Plan. Referrals identified in preadmission assessments must be undertaken. 31 32. YA19 YA19 12(1,a) 15 13(1,b) 01/02/05 01/12/05 Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 33 33. YA19 13(4,b-c) 34. YA19 13(4,c) 12(1,a) 35. 36 37 YA19 YA20 YA20 12(1,a) 13(4,c) 13(2) 13(2) 38 39 40 YA20 YA20 YA20 13(2) 13(2) 13(2) 41 YA20 13(2) 42 YA20 13(2) 43 YA23 13(6) 44 YA42YA24 13(6) Reactive Management Plans must be available to support the needs of service users with difficult to manage behaviours. Staff interventions and distractions available for one service user with repetitive behaviour must be reviewed, and improved. All known needs must be included in a plan of care to include pain and Epilepsy. Adequate safe storage must be provided for all medicines. The drugs fridge temperature must be taken consistently. The drugs fridge must be repaired or replaced. Copies of current FP10 prescriptions must be available in the home. Non-blister packed medicines must be audited, to ensure they are given as prescribed. Protocols for as required medicines must be further developed, and kept under review. Changes in service users medication must be clearly written on the medication administration record. All administered medicine must be signed for, or the relevant code entered onto the Medicine administration record. All staff must receive refresher training in Adult Protection, and the procedure in event of a disclosure being made. The home must be operated in a way that ensures service users safety. 01/12/05 01/12/05 01/01/06 01/01/06 01/12/05 01/12/05 01/12/05 01/01/06 01/12/05 01/12/05 14/12/05 01/12/05 Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 34 45 YA42YA24 13(4,c) 46 47. YA26 YA26 23(2,d) 23(2,b) Building and repair works 01/12/05 must be effectively scheduled to ensure the welfare and safety of service users is maintained. Service users must be offered 01/12/05 support to maintain their room in a clean and tidy condition. Unmet from the previous 01/12/05 inspection. Rooms must be presented to a satisfactory and safe standard prior to service users moving in to them. Bathrooms on the first and second floor. Work is underway. The ground floor toilet must be upgraded and presented to an acceptable standard. The ground floor bathroom must be reviewed to ensure safe assisted bathing facilities are provided. One-service users walking aid must be repaired. Unmet from the previous two inspections. Light chords in bathrooms require cleansing or replacement. Unmet from the previous two inspections. Odour control must be maintained in all areas of the home. Standards of cleanliness must be maintained at a satisfactory level in all areas of the home. 48 49. YA27 YA27 23(2,d,j) 23(2,b) 23(2,j) 02/02/06 01/12/05 50 YA29 23(2,n) 01/12/05 51 52. YA29 YA30 23(2,n) 13(3) 01/12/05 01/01/06 53. YA30 16(2,k) 23(2,d) 01/12/05 Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 35 54. YA30 13(3) Unmet from the previous two inspections. Food must be wrapped and labelled with the date of opening. All open foods must be appropriately stored. Unmet from the previous two inspections. A review of the morning staffing must be undertaken, and action as identified implemented. Adequate numbers of staff must be provided to safely meet service users needs, and to cover staff breaks. Unmet from the previous inspection. Recruitment records must evidence that robust checks have been undertaken prior to staff commencing work in the home. Unmet from the previous inspection. 01/12/05 55. YA33 18(1,a) 01/01/06 56 YA33 18(1,a) 01/12/05 57. YA34 19 01/12/05 58. YA35 18(c) 01/02/05 59 YA36 18(2) Mandatory and service user specific training must be delivered to staff as required. Evidence this has been planned and delivered must be maintained in the home Unmet from the previous 01/02/06 inspection. All staff must receive supervisions at least bimonthly, and a record of these maintained. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 36 60. YA37 8&9 Unmet from the previous inspection. The management arrangements of the home must be reviewed to ensure these are effective and adequate Not assessed at this inspection. 01/12/05 61. YA41 13(6) 01/01/06 62. YA41 17 The service users financial profiles must be accurate. The personal allowance paid to one service user must be reviewed to ensure this is the full amount. (Refund of any underpaid funds must be made) Service users must have individual bank accounts. Unmet from the previous 01/12/05 inspection. Records (Including records of food) must be in order, dated auditable and fully completed. All incidents and accidents must be notified to the CSCI without undue delay. Not assessed at this inspection. COSHH hazard sheets must be reviewed and updated. Unmet from the previous inspection. Risk assessments must be developed to underpin the risks and detail the control measures for staff when at work. 63 64. YA41 YA42 37 13(4,a-c) 01/12/05 01/01/06 65. YA42 13(4,a-c) 01/01/06 Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 37 66. YA42 12(1,a) 13(6) Unmet from the previous two inspections. Locks on service users doors must be reviewed, to ensure service users welfare and freedom of movement is maintained. Not assessed at this inspection. The information obtained from the accident report audit must be utilised to reduce the likelihood or repeat of similar incidents. Unmet from the previous inspection. The fire risk assessment must be developed to show control measures for concerns/issues that have been raised. A current Landlords Gas safety certificate must be obtained. Risk assessments for the premises must be kept under review and updated as changes occur. Staff must be given awareness training in the use of the washing machine and sluice cycle. Full bags of clinical waste must be safely stored and discarded of. Adequate fire safety systems must be fitted in the laundry room. 01/01/06 67. YA42 13(4,a-c) 01/02/06 68. YA42 23(4,a) 01/01/06 69. 70. YA42 YA42 23(2,c) 13(4,c) 01/12/05 01/12/05 71. YA42 23(2,k) 01/12/05 72 73 YA42 YA42 16(2,k) 23(4,c,i) 01/12/05 01/12/05 Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 38 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 YA18 Good Practice Recommendations Unmet from the previous inspection. It is recommended that the use of the personal care matrix be reviewed. Greenhill Road, 29, (westholme) DS0000016713.V260963.R01.S.doc Version 5.0 Page 39 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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