Inspection on 16/06/05 for 2 & 10 Grove Road

This inspection was carried out on 16th June 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

2 & 10 Grove Road 21/05/08

2 & 10 Grove Road 04/05/07

2 & 10 Grove Road 26/04/06

2 & 10 Grove Road 02/11/05

2 & 10 Grove Road 26/07/04

2 & 10 Grove Road 12/03/04

2 & 10 Grove Road 05/09/03

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

CARE HOME ADULTS 18-65 Grove Road 2 & 10 Kings Heath Birmingham B14 6ST Lead Inspector Kerry Coulter Announced 16 June 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Grove rd, 2 & 10 Address Kings Heath Birmingham B14 6ST Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 441 3221 0121 441 3541 SENSE West Vacant Care Home 8 Category(ies) of Care Home registration, with number 8 of places Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. 2. The home may provide care for up to 8 service users requiring personal care by reason of combined learning disability & sensory impairments. Date of last inspection 13/12/05 Brief Description of the Service: Grove Road is located in a small cul-de-sac in a residential area of Kings Heath. The Home comprises of two purpose built properties each accommodating four service users with learning disability and sensory impairment. Grove Road is within reasonable walking distance of the main shopping area of Kings Heath, where there are numerous shops, public houses, restaurants, churches and recreational amenities. There is a large park close by and public transport is easily accessible. 2 & 10 Grove Road is on opposite sides of the cul-de-sac. Each house has a lounge and a separate dining room, a modern fitted kitchen and a small laundry room. The administrative office is located at number 2 and the staff sleeping in room at number 10. Number 2 also benefits from the addition of a conservatory, which gives additional space. All service users’ bedrooms are of single occupancy and are decorated and furnished to reflect individual interests and personalities. There are bath and shower facilities in the upstairs bathroom plus separate toilets on the landing and on the ground floor. Both homes are comfortable and well furnished and there are many aids and adaptations related to sensory and other disabilities. There are four male service users living at number 2 whilst at number 10 there is a mixed gender group. The service users have diverse cultural backgrounds, which are reflected in the choice of decoration and furnishings. Both properties have rear gardens. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over one day. Conversations with the deaf/blind people were limited due to their complex needs and limited verbal communication abilities. However, the inspector spent time with the deaf/blind people observing care practices, interactions and support from staff. A tour of both buildings was made. Care plans and risk assessments were inspected. Staff training and recruitment procedures were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the acting manager, practice development worker and informally with support workers. In addition to information provided in response to the pre-inspection questionnaire, feedback was received from relatives and the Chiropodist. What the service does well: What has improved since the last inspection? The home has further developed the statement of purpose and service user guide. These documents now contain all the required information about the home and attempts have been made to present this in a more accessible format through the use of pictures and symbols. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 6 The care plans of some individuals at the home are now up to date and contain clear guidance on how to support them. Health action plans have been introduced. This is a plan that records everything an individual needs to stay healthy. Some internal redecoration has taken place making the environment a more pleasant place to live. What 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. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 4 and 5 The Statement of Purpose and Service User Guide provide the information needed to make an informed choice about services provided, and this is reinforced by assessment and admission procedures. Individual contracts need to be updated to provide clear and current information. EVIDENCE: Since the last inspection in December 2004 the home has further developed the statement of purpose and service user guide. These documents now contain all the required information about the home and attempts have been made to present this in a more accessible format through the use of pictures and symbols. SENSE as an organisation is also working towards alternative formats to include audio tape, photo’s and CD Rom, thereby increasing their accessibility to the people who live at the home. One deaf/blind person has recently moved into Grove Road from another of SENSE’ s care homes. Evidence of assessment prior to admission was observed to include involvement from other professionals and relatives. Review meetings took place and a transition plan had been completed. The deaf/blind person had the opportunity to visit Grove Road before admission. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 9 As identified in previous inspection reports individual contracts should be reviewed so that they show clearly the current cost of the service and indicate specifically service users’ and other parties’ contributions and charges. Ideally, contracts should be signed by the individual concerned, where possible. In cases where individuals are unable to sign, the opportunity for the contract to be countersigned by a relative, friend or independent third party should be seen as standard good practice. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 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 standard(s) 6, 7, 9 Not all care plans have been kept under review, this has the potential to cause inconsistencies in the care given to the deaf/blind person. People are supported to take responsible risks, but some work needs to be done on the ways in which risks are assessed and how this information is presented. EVIDENCE: Discussions took place with the Practice Development Worker (PDW) regarding the system for care planning, three care plans were also sampled. Some care plans have not been reviewed in the last six months and staff at the home are working towards ensuring this is done. The PDW was able to evidence that the care plans for some deaf/blind people had been recently reviewed and further developed since the last inspection. The updated plans were observed to contain satisfactory guidance on the support required by the individual. The PDW clearly understood his role and was enthusiastic with further ideas to develop the care planning process. Evidence was available that other professionals are involved in the care of people who live at the home, for example the Speech and Language Therapist has completed assessments for eating and drinking. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 11 Part of the PDW role is to undertake practice observations of staff working with deaf/blind people. SENSE has documentation to be completed following the observation. It is recommended that the document is amended to record if staff practice is in line with the care plan as this appears to be part of the purpose of the observation. Members of staff actively encourage each deaf/blind person to take responsibility for as many things are they are able, within their individual capabilities. They seek to promote choice wherever possible, and respect the choices people make. Individuals’ communication difficulties place some restrictions on how this is put into practice. Where possible, attempts are made to overcome this, for example, through the use of objects of reference. Work is underway to improve risk assessments. Risk assessment summaries have been completed to give the reader a quick reference to the assessments in place for each individual. Some risk assessments were observed to require review, in particular for the deaf/blind person new to the home. Work also needs to be undertaken to ensure each risk assessment includes the level of risk, ie low, medium or high. Each risk assessment should be directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other. If an index is used, it must be accurate and up to date. One of the outcomes for completing risk assessments and care plans should be that the finished article is a simple and effective working document, in which essential information can be easily found. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15, 16 and 17 A range of activities is offered in order to promote personal development, participation in the life of the local community and enjoyable leisure time but the quality of the recording of cancelled activities is variable. Staff offer appropriate support to enable individuals to maintain contact with relatives. Healthy and nutritious meals are provided and people who live at the home exercise choice about what they eat. EVIDENCE: The care plans contained a “Schedule of activity”. People who live at the home take part in a variety of daytime activities including swimming, music, art, rock climbing, gym, canoeing, horse riding and rambling. This was also evidenced through daily records, photographs displayed and discussions with staff at the time of the visit. The Practice Development Worker completes a monthly audit of activities participated in. The audit is based on the number of activities Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 13 occurring. Consideration should be given to auditing the quality of the activity to include if it is the choice of the individual rather than an alternative activity. Records indicate that on a limited number of occasions planned activities have not taken place and alternatives have been offered. The Manager must ensure that staff record why the planned activity did not occur as this is not being consistently recorded. There have been some issues of activities not taking place due to seating issues in the bus. Discussion with the Manager indicates that this has been resolved, this will need to be kept under review. The home has a visitor’s policy and actively encourages visits from family and friends. There was evidence that relatives also have contact by the telephone and letters /cards. It is an area of good practice that SENSE employs a Family Liason Officer, she had been involved with relatives in the process of the new admission to the home. Additionally, a family weekend is also arranged at a local hotel where relatives can meet with SENSE representatives and other relatives. Four comment cards were received from relatives. These were generally positive content but one recorded that there was insufficient staff on duty, this was not however the majority view. Comments included ‘my son is happy and well cared for’ and ‘we are happy with the placement’. Staff were observed interacting and communicating with the people who live at the home, ascertaining their wishes. The menus inspected showed that the food was varied, wholesome and nutritious. People who live at the home assist in the shopping for food and help to prepare and cook the food that they have bought. The food actually eaten is recorded in detail in the daily records. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 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 standard(s) 19 and 20 EVIDENCE: The files of three deaf/blind people were sampled. These showed information relating to healthcare appointments including visits to clinics and specialist consultants. All individuals are registered with a local GP and detailed records are kept of all health appointments by the staff. Records sampled and discussion with the Manager evidenced that one individual who has diabetes receives satisfactory support from staff and the Community Nurse to manage the condition. Records included regular visits to the dentist and optician and visits from the community nurse as appropriate. The CSCI comment card completed by the home’s chiropodist did not record any concerns about the home. Since the last inspection health action plans have been introduced. This is a plan that records everything an individual needs to stay healthy. Good work has been done in seeking to identify and systematically record individuals’ health needs. This should now be built on so that the document moves from being a statement of need to a planning and monitoring tool. The medication administration system was sampled. None of the people who live at the home are able to manage their own medication. Medicines were seen to be stored appropriately in a secure location. Clear, written guidance was available on the administration of ‘as required’ medication. A random Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 15 audit of stocks revealed no discrepancies, and there were no gaps on the administration record. However, paracetamol was stored that had been dispensed in 2004 and 2003. This needs to be returned to the pharmacist and new stock ordered. Such supplies should be held for a maximum of six months. Discussion with the Manager indicates that two staff are yet to complete the medication training course. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 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 standard(s) 22 and 23 The home has a satisfactory complaints procedure. Adult protection systems are lacking and impact on the homes ability to ensure service users are being protected from abuse and their welfare promoted. EVIDENCE: The deaf/blind people due to their complex needs are not able to make a complaint and are reliant on staff, relatives or an advocate to act on their behalf. The homes complaints log indicated that no complaints had been received by the home. The organisation Sense had produced a new policy referred to as ‘issues policy’. This was assessed as meeting the required standard at previous inspections. The Manager stated that the procedure was now available in a variety of formats to include Widget symbols and a CD Rom with pictures. CSCI were formally notified of an internal investigation in the home. The outcome led to the organisation taking disciplinary action against staff. Evidence was observed that staff have received adult protection training. Systems are in place to safeguard the monies of people living at the home. Receipts for expenditure were available and numbered. Staff count and check the balance of monies held at each handover. The record of this is not always signed by two members of staff, it is strongly recommended that this is done to increase the safeguards in place. Two staff files were sampled. One file did not contain evidence of a CRB check being completed. The Manager and the staff concerned stated that a check had been completed, the Manager stated he would forward this to the CSCI. At the time of writing this report this had not been received. Evidence of this must be available in the home. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 28, 29 and 30 The standard of the environment within this home is good providing individuals with an attractive and homely place to live and meeting their needs. The standard of maintenance of the gardens was variable meaning that not all individuals had a pleasant and accessible garden. EVIDENCE: The two houses are in keeping with the local community. Both were found to be clean at the time of the visit. There were no offensive odours in the houses Improvements have been made to the interior of the houses since the last inspection. Some repainting is underway with other parts of the homes identified for improvement. Bedrooms sampled were observed to be personalised according to individual needs and preferences. Some bedrooms have areas that are not fully accessible due to a sloping roof, this is not ideal where the individual has a visual impairment. Suitable adaptations have been made to the home to ensure it meets the needs of individuals with a sensory impairment. This includes objects of Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 18 reference attached to doors so individuals know where they are in the home and bedrooms have appropriate systems installed to alert individuals to someone entering their room. House 10 has a pleasant rear but the garden in house 2 is somewhat overgrown. The Manager stated there had been some issues with the gardening contract but that he anticipated this would soon be resolved. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 36 Staff have a good understanding of residents’ needs and the care team is appropriately qualified. The current reliance on bank and agency staff needs to be reduced by recruiting to vacant posts. There is a continuous training programme in place for staff, and this should be developed further in accordance with residents’ assessed needs. Staff are generally well supported, but formal supervision in accordance with required standards needs to be better established. EVIDENCE: It was noted that both staff and the people who live in the home appear comfortable in each other’s company. Staff spoke with had a good understanding of the needs of the people in their care. The home provides a minimum of two care staff per day shift not including the Manager and Practice Development Worker. Additionally, extra hours are provided on a 1:1 basis for one individual who requires extra support, pending a planned move to another care home. This 1:1 staffing is generally being Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 20 covered by agency staff. The Manager stated he tries to ensure that regular agency staff are used but this is not always possible. The home does have some staff vacancies, 4 posts in total. Bank or agency staff are employed to cover these, and attempts are made to restrict the number of unfamiliar people working in the house by using the same core group where possible, in the interests of promoting continuity of care. Recruitment to these vacant posts must be dealt with as a matter of priority. The Manager stated that one potential new member of staff had been recruited subject to the appropriate checks being satisfactory. Information from the pre inspection questionnaire records that 9 staff have completed an NVQ in care whilst other staff are working towards this. This exceeds the target of 50 of staff having an NVQ. The schedule for staff training was seen. This evidenced that SENSE has a rolling programme of training for staff to include adult protection, first aid, food hygiene and deaf blind awareness. Some staff are due refresher training. Evidence indicates that this is sometimes requested from the training department but that sometimes the courses are full and difficult to access. SENSE needs to consider increasing its capacity or frequency of training to ensure Managers are not having to reapply for some staff training. In view of the assessed needs of the deaf/blind people it is required that additional training in supporting people with epilepsy and diabetes should form part of the core programme for this house. Records of supervision were sampled for three members of staff. Two members of staff had received regular supervision but this was not evident for one staff who works nights whose last recorded supervision was in December 2004. The Manager stated that one supervision had been done since but had unfortunately not been recorded. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 An effective quality assurance system is in place. Systems are in place to promote the health and safety of service users but some areas of risk had been overlooked. EVIDENCE: Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 22 Systems are in place to assure quality. This includes monthly visits to the home by the general manager who completes a report and forwards this to the CSCI. Audits are carried out periodically to include the staff files by personnel. Additionally, part of the role of the practice development worker is to complete quality assurance audits this includes the level of activities on offer. Health and safety at the home was generally well managed. The home has a range of policies, procedures and systems in place to comply with the requirements of health and safety legislation all of which are made known to staff both verbally and in written form as part of their induction. Risk assessments are in place for the premises, fire, food hygiene, service users and staff. The home has two very large folders of risk assessments and it can be time consuming to locate a specific assessment. As an aid to staff quick reference risk assessments for service users have been completed since the last inspection summarising the assessments in place. As stated earlier in the report attention is needed to detailing the level of risk within the assessments. In-house checks on the fire equipment, fire and fire drills had been completed appropriately. It was required that another fire drill should be arranged for house 10 due to the new person moving in. The emergency lighting had been tested but there had been a gap in testing prior to May. T here was evidence on site of the servicing of all equipment. COSHH substances were stored securely and not a risk to service users. Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 23 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 3 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x 2 3 3 Standard No 11 12 13 14 15 16 17 x 2 3 3 4 3 3 Standard No 31 32 33 34 35 36 Score x x 2 x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grove Road 2 & 10 Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 5 Regulation 5(1) Requirement A copy of a written contract / statement of terms and conditions, detailing the required information needs to be available in the home. In needs to specify the room to be occupied, fees, term and conditions, facilities and support. Service user or their representative and manager should sign it. Outstanding requirement from 31/10/04. Individual care plans must be reviewed at least every six months or as needs dictate. Outstanding requirement from 30/9/04. The risk assessments for the deaf/blind person new to the home require review to reflect the new environment. Ensure risk assessments are reviewed at least six monthly, record the level of risk and cross reference to/ from the relevant care plan(s). The home must effectivley monitor the number of planned activities that do not take place. Improvement is needed to the recording of why planned Timescale for action 30/8/05 2. 6 15 30/8/05 3. 9 13(4) 4. 9 13(4) 30/6/05 Immediate requiremen t 30/8/05 5. 12 16(2)(mn) 30/8/05 Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 25 6. 20 13(2) 7. 20 & 35 13(2) & 18(1)(a) 8. 9. 23 24 & 28 13(6) 23(2) 10. 11. 33 35 18(1)(a) 18(1)(c) 12. 35 18(1)(c) 13. 14. 36 42 18(2) 13(4) & 23 13(4) & 23 activities do not occur and how choice of alternative activrties was made. Medication stocks should be reatained for no longer than six months after the date of dispensing. The staff group require training in medication. Training for care staff must be accredited and must include basic knowledge of how medicines are used and how to deal with problems in use and the principles behind all aspects of the home’s policy on medicines handling and records. (Two staff still to do). Outstanding requirement from 30/11/04. Evidence of CRB checks being completed must be available in the home for all staff employed. Attention is required to the general maintanence of the garden at house 2 to ensure it is a pleasant and safe area for people who live at the home. Vacant staff posts must be recruited to. SENSE needs to consider increasing its capacity or frequency of training to ensure Managers are not having to reapply for some staff training. Training in supporting people with epilepsy and diabetes should form part of the core programme for this house. Staff must receive supervision at least six times per year. A fire drill must be arranged for house 10 due to new service user moving in. The emergency lighting must be tested monthly, done in May but gap prior to that. 30/7/05 30/9/05 30/7/05 15/8/05 30/8/05 30/8/05 30/9/05 30/8/05 30/6/05 Immediate requiremen t 30/6/05 Immediate requiremen t Page 26 15. 42 Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 6 Good Practice Recommendations Record of practice observations - It is recommended that the document is amended to record if staff practice is in line with the care plan as this appears to be part of the purpose of the observation. When staff count and check service users monies at handover it is good practice for two staff to sign the record. 2. 23 Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Grove Road 2 & 10 E54_S16795_GroveRd_V224581_160605 - Stage 4.doc Version 1.30 Page 28 - 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. 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