CARE HOME ADULTS 18-65
Hamstead Hall Road, 43 Handsworth Wood Birmingham West Midlands B20 1HT Lead Inspector
Gerard Hammond Unannounced Inspection 21st & 26th October 2005 02:15 Hamstead Hall Road, 43 DS0000016929.V260960.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 Hamstead Hall Road, 43 DS0000016929.V260960.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. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Hamstead Hall Road, 43 Address Handsworth Wood Birmingham West Midlands B20 1HT 0121 523 5472 0121 523 5472 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) Milbury Care Services Limited Ms Veronica Christopher-Fellows Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home may provide care for four (4) service users with a learning disability aged under 65 years. 5th January 2005 Date of last inspection Brief Description of the Service: 43 Hamstead Hall Road is registered to provide accommodation, care and support for four people who have learning disabilities. The Home is run by Milbury Care Services, and the current resident group of four men have been together for a number of years. The house is a domestic scale detached property, located in a quiet, wellestablished residential neighbourhood in the Handsworth Wood area of Birmingham. There are good public transport links for this locality. Downstairs there is a comfortable lounge to the front of the house. There is a separate dining room at the back of the house, and this gives access to the garden through patio doors. There is also a kitchen, separate laundry and toilet on this floor. All of the bedrooms are situated on the first floor, accessed by the staircase leading from the front hallway. There are two single rooms and one double, currently shared by two brothers. A small “box” room serves as an office. The domestic scale bathroom includes toilet facilities. There is a paved driveway at the front of the house offering limited parking. To the rear of the property is a private enclosed garden. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over two visits. Direct observation and sampling of records (including care plans, personal files, previous inspection reports and safety records) were used for the purposes of compiling this report. The Inspector met all of the residents. People’s learning disabilities and their communication support needs meant that it was not possible to seek their views directly. The Registered Manager was formally interviewed, and three other members of staff seen informally. A tour of the premises was also completed. What the service does well: What has improved since the last inspection?
Positive efforts have been made to meet requirements made at the time of the last inspection. Significant improvements have been made to the house through thoughtful use of colour and contrast in the redecoration of communal areas. This is particularly important for one man, who has visual impairment. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 6 Specialist equipment has also been purchased and installed in this man’s room to enhance his personal independence and safety by making him aware when there is someone at the door, and also when the fire alarm is activated. Staffing arrangements have also improved considerably. Night-time cover is now provided by waking night staff. Vacant posts have now been filled, subject to satisfactory references and CRB clearance. Agency staff are now required to show official proof of identity before being allowed on shift. Working practices with regard to daily recording has improved, and staff are now signing entries, as required. Opportunities for staff to receive formal supervision are now back up to standard, with efforts being made to improve this further. Some progress has been made towards obtaining specialist support for one resident with sensory impairments, and this now needs to be pursued vigorously. What they could do better:
The complex, high support care needs of the people living at 43 Hamstead Hall Road means that the information that has to be maintained on their personal files is substantial. Managing this information so that it is accessible at all times is a significant challenge. Personal files need to be “tidied up” and material that is no longer current should be removed. This should help to make essential information easier to find. Care plans need to be developed to include people’s goals. Each goal should have an outcome that can be measured. In this way it should be possible to see what is working and what might need to be changed, when the plan is reviewed. Some work also needs to be done on risk assessments. It is important that the information produced by doing risk assessments gets included in people’s care plans. There should be clear links between care plans and risk assessments so that people are directed easily from one to the other. Numbering and indexing plans and assessments make it easier to cross-reference them both. Unused PRN (“as required”) medication that is dispensed in blister packs should be returned to the pharmacy once the recommended eight-week storage period has elapsed. The window in one resident’s bedroom has not been functional now for some time, and attempts to repair it have proved unsuccessful. It should be replaced with a new window, so that it can be opened and closed properly. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 7 The carpet in the box room office is badly stained and should be replaced. The shelf unit in this room is unsafe, and needs to be secured to the wall, so as to prevent an accident occurring. Some improvement is needed to the arrangements for testing the fire alarm each week, and keeping a record of such tests, as required. 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. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 8 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 Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 9 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 Residents’ needs are assessed appropriately, and action is being taken to ensure that the service can meet the needs of all the people living in the house. EVIDENCE: There have been no admissions since the time of the last inspection. The current group of four residents have lived together for a number of years. Sampling of personal records provided evidence of detailed information concerning the support needs of the people living in the house. At the last inspection some concerns were raised about the capacity of the service to meet the specialist needs of one resident, who has sensory impairment. Since that time additional equipment has been purchased to assist in this, and further specialised support is being sought, so as to improve his quality of life, and the opportunities available to him. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care plans currently contain a wealth of detailed information, but this needs to be better organised and presented. Care plans should be developed to include goals with outcomes that can be measured. Residents are supported to make decisions and choices about their lives. Responsible risk taking is encouraged and supported, so as to enhance personal independence, but risk assessments are in need of development. EVIDENCE: All of the people living in this house have complex high support needs. A sample check of personal records found a large volume of information required to support residents’ care needs. Much of this information is of good quality and appropriately detailed, and it is clear that a lot of hard work has gone into compiling and maintaining it. However, it is not currently presented in a way that lends itself to locating information easily. A new member of staff or an agency worker would have difficulty finding their way through the large files in their present form. Removing old material from the files and disposing or archiving it as appropriate could improve information management. It is important that care records are accessible, working documents. It should be
Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 11 acknowledged that the sheer volume of material that has to be kept for people with complex high support needs poses particular problems in this regard. Individual care plans should include goals with outcomes that can be measured. Targets set should be evaluated at review, and changed or reset as appropriate. This provides a benchmark against which to assess whether or not care plan objectives are being met. Whole care plans should be reviewed at least every six months, with written records kept, indicating who takes part and how decisions are made. There seems to be some confusion about the difference between risk assessments and care plans. Risk assessments should seek to identify any hazards associated with particular activities or situations. The assessment should then indicate the likelihood of the hazard occurring. The outcome of the risk assessment is the control measures designed to eradicate or minimise the likelihood of the hazard actually occurring. The control measures should then be used to inform the care plan. In many cases, this will mean that the control measures are simply lifted out of the risk assessment and put into the care plan, but it is essential that this information gets included in the plan. It is important that risk assessments are directly cross-referenced to the care plan(s) to which they relate, and vice versa. Numbering and indexing assessments and care plans facilitates this process. There were indices for both care plans and assessments, and this good practice should be built upon, so that it becomes easier to “track” from one to the other. However, it is clear that responsible risk taking is supported appropriately, so as to enhance residents’ opportunities for personal independence. Direct observations provided evidence that residents are also supported to make decisions and choices about aspects of their daily lives. This is restricted to a degree by individuals’ learning disabilities and personal capacity. However, several good examples of alternative communication aides were seen in the house, and staff were observed offering residents choices about meals and drinks and also activities. It is recommended that detailed communication guidelines be further developed; ensuring that all the detailed knowledge that the staff team has about how people communicate is recorded and included. These should placed prominently on individuals’ care plans. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Residents are able to take part in appropriate activities, and to be part of the life of the community in which they live. People living in the house are supported to keep in touch with their families and friends. Staff respect residents’ rights and encourage them to be as independent as they are able. Residents have access to a diet that is balanced and sufficiently nutritious. EVIDENCE: Residents all have structured programmes that include attendance at local colleges and activities in the local community. Having lived in the neighbourhood for several years, residents are well known in the local community, particularly local shops, the pub and the barbers. Records show that people also access the cinema, swimming baths, restaurants and the library. They are also actively involved in doing the shopping for the household
Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 13 at the local supermarket. In addition to travelling by car, residents also make use of public transport facilities. Some progress has been made towards securing specialist support for the activity programme of one resident who has sensory impairment. Appropriate assessments have been conducted and positive action has been taken to enhance opportunities within the home. This needs to be extended to his day programme, and this matter should now be pursued as a matter of priority with the commissioning authority. Staff support residents to keep in touch with their families and friends. Two of the residents are brothers, and they receive regular visits from a close family friend, who keeps in touch now that their parents have passed away. One resident has no family contact and attempts by staff to find an independent advocate / friend for him have, regrettably, proved unsuccessful to date. However, this man in particular is well known in the neighbourhood, and he is quite successful at maintaining social contact outside the home in this way. Members of staff were observed encouraging residents to do things for themselves and to be as independent as their individual abilities allow. They enjoy freedom of movement within their home, with the exception of some restrictions to access in the kitchen. Previous reports indicate that this has been appropriately risk assessed and kept under review. Food stocks were examined and seen to be adequate, with fresh produce available. There are pictorial aides to assist residents make menu choices. Personal records contained information about individual preferences. The record of meals provided indicated that residents have access to a sufficiently balanced and nutritious diet. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Residents receive personal support in accordance with their requirements and preferences, and their healthcare needs are met appropriately. General practice in the handling and administration of medication is good, but PRN medication stored in blister packs must be returned to the pharmacy within the recommended period. EVIDENCE: It is evident from residents’ personal grooming and attire that they receive a good standard of basic personal care. Residents and staff are relaxed and at ease in each other’s company. Interactions were seen to be warm and friendly, and support offered in ways that were considerate and appropriately respectful. Residents’ medical notes indicated that primary and specialist healthcare support is being accessed in accordance with people’s needs. Healthcare professionals including GP, Consultant Psychiatrist, Psychologist, Chiropodist, Optician, and Dentist have seen residents on a regular basis. Health Action Plans are on file and have been reviewed. The Accident Book was examined, and completed accident reports have been filed on people’s records as appropriate, in accordance with current data protection legislation. It is
Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 15 recommended that the counterfoil stub in the Accident Book be marked with the initials of the person concerned and the date of the report, so that these can be tracked if required. The Medication Administration Record (MAR) was examined and had been completed appropriately. The record included a photograph of each resident, guidelines for administering medication, and appropriate protocols were in place for PRN (“as required”) medication and epilepsy management. However, it was noted that PRN medication stored in blister packs was stored beyond the recommended eight-week period. A requirement was made that these stocks are returned to the pharmacy and replacements obtained as appropriate. It is also recommended that the schedule for defrosting the medication fridge be amended slightly to include the next due date. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 It is difficult to assess whether or not residents feel that their views are listened to and acted upon. General practice protects residents from abuse, neglect and self-harm. EVIDENCE: An appropriate complaints procedure is in place. The Complaints Book was examined: as reported at previous inspections there has been a longstanding issue with a neighbour concerning problems with shared drains. The record showed that complaints made had been investigated appropriately and prompt action taken. The Manager advised that all staff have received training in the Protection of Vulnerable Adults From Abuse. A copy of the local multi-agency guidelines on adult protection is available in the Home, and the Organisation’s own policy is also in place. A previous requirement that agency staff are required to produce official proof of identity, before being allowed to come on shift, is now being implemented. A sample check on residents’ personal finances found that the balance of money held tallied with the written account, and that receipts were in place, as required. Residents are dependent on the vigilance of members of staff and on their ability to interpret “body language” or changes in behaviour or general demeanour, to know that they are concerned or upset.
Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 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 the following standard(s): 24, 25, 26, 28, 29 & 30 Residents live in a house that is safe, comfortable and homely. People’s rooms suit their needs and promote their independence, though one resident has a window in his room that does not operate satisfactorily. Communal spaces in the house complement residents’ individual rooms. Specialist equipment is available to support residents’ personal independence. The home is clean and tidy, and a good standard of hygiene maintained. EVIDENCE: Residents at 43 Hamstead Hall Road enjoy the benefit of living in a house that is comfortable and safe, offering them a warm and welcoming living environment. Although not excessively spacious, the house meets the needs of the current resident group, but would not be suitable for someone with significant mobility problems. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 18 Substantial redecoration to communal areas has been completed, as required at the time of the last inspection. This is of particular benefit to one resident who has visual impairment, as consideration has been given to the use of contrasting colours to define areas more clearly. Specialist equipment has also now been purchased and installed to alert this man to people wishing to enter his room, and also to the fire alarm sounding. Residents’ rooms are individual in style with personal possessions and effects in evidence. The two men sharing a double room are brothers, and efforts have been made to divide the room appropriately to provide each of them with privacy. Designated repairs to the bathroom have also been completed, and lidded bins provided as required. The “box” room is now no longer required as the staff sleep-in facility, and is now used only as an office. The carpet in this room is badly stained, and should be replaced. The freestanding shelf unit is unstable and constitutes a risk to health and safety. An immediate requirement was made that this should be fixed to the wall. A requirement was made at the time of the last inspection that the window in the rear single bedroom should be repaired so that it closes properly. The manager advised that this has been attended to since then, but on the day of the inspection visit it still did not operate satisfactorily. The window is old and should be replaced. The house is kept clean and tidy, and a good standard of hygiene maintained. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 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 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, 35 & 36 The staff team is appropriately qualified, knowledgeable about the needs of people living in the house, and now up to complement. A training and development plan is required to assess the team’s training needs fully. Staff are supported and supervised appropriately. EVIDENCE: Conversations with members of staff revealed a good knowledge of residents and their general support needs. The previous inspection report indicated that the number of staff qualified to NVQ 2 met the required standard. Since then, the service has changed to provide waking night staff cover. Previously vacant posts have now been filled, subject to satisfactory references and CRB clearance, and the Manager advised that there were currently no staffing vacancies. Recruitment practice was not fully assessed on this occasion, though it is known that the Organisation deals with this from a central location. A current staff training and development assessment and plan is required. The plan should show (for each member of staff employed at the Home) details of all qualifications obtained and training completed. It should highlight any gaps (including “refreshers”) and indicate when outstanding training is scheduled and who is to deliver it.
Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 20 Records show that staff meetings are held on a regular basis. Sample checks of individual staff personal files indicate that formal supervision is up to standard, and the Manager advised that it is her intention to work towards increasing the frequency to achieve monthly meetings. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 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 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 Residents benefit from living in a home that is well run, and a management team that is open and approachable. Record keeping is generally up to standard. General practice promotes the health, safety and welfare of people living in the house. EVIDENCE: The Manager is qualified to NVQ level 4 (since 2001) and has recently obtained the Registered Manager’s Award (July 2005). Previous inspection reports have alluded to her open and inclusive management style, and throughout this inspection she demonstrated a positive attitude and a willingness to develop the service for the benefit of the people living in the house. She also indicated that she felt well supported by her Service Manager. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 22 Records are generally well maintained. A requirement made at the time of the last inspection with regard to ensuring that staff signed entries in residents’ daily records is now being met. Safety records were sample checked. The fire alarm system and fire-fighting equipment have been serviced. The weekly test of the fire alarm is generally being done, but there were some gaps in the record. A fire evacuation drill should now be held so as to comply with the standard, which is at least every six months. The record should show the names of all those taking part. Portable appliance testing of electrical equipment is also now due, but this is in hand and an appointment to carry out this work was confirmed by telephone on the day of the inspection visit. The Landlord’s Gas Safety Certificate and the five-year electrical hard wiring certificates are both in date. Checks of water temperatures and Legionella testing have been carried out. Fridge and freezer and cooked food temperatures are also being checked regularly, as required, and packages of food stored in the fridge are labelled with the date of opening. The store for COSHH products was secure. Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 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 X 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 2 3 X 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Hamstead Hall Road, 43 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X 3 3 X DS0000016929.V260960.R01.S.doc Version 5.0 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 YA6 Regulation 15 Requirement Individual care plans should be developed to include goals with measurable outcomes. These should be evaluated at review, and amended or reset as required. Risk assessments should be cross-referenced to the care plan(s) to which they relate, and vice versa. Ensure that control measures are included in individual care plans. Unused PRN (“as required”) medication dispensed in blister packs must be returned to the pharmacy once the recommended eight-week storage period has elapsed. (Immediate requirement) Replace the window in the rear single bedroom A full copy of an Enhanced Disclosure must be obtained from the Criminal Records Bureau, so as to enable an appropriate judgement to be made about an applicant’s suitability to work with vulnerable adults. Outstanding since 30/01/05 –
DS0000016929.V260960.R01.S.doc Timescale for action 31/01/06 2 YA9 13 (4) 31/01/06 3 YA20 13 (2) 27/10/05 4 5 YA25 YA34 23 (2b) 19 31/01/06 31/12/05 Hamstead Hall Road, 43 Version 5.0 Page 25 (5) 6 YA35 18 (1c) not assessed at this inspection. A training and development plan including all the information detailed in the main body of this report should be forwarded to CSCI. Ensure that the fire alarm is tested each week, and that a written record of such tests is maintained. Arrange for fire evacuation drills to take place at least every six months, and keep a written record showing the names of all who take part. 31/01/06 7 YA42 13 (4c) 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations Remove material from personal files that is not current, and dispose of it or archive as appropriate. Build on the excellent work already done to develop clear communication guidelines for each resident, and place these prominently on individual care plans. Mark the counterfoil stubs in the Accident Book with the initials of the person concerned and the date of the report. Amend the schedule for defrosting the medication fridge to show the next due date. 2 3 YA19 YA20 Hamstead Hall Road, 43 DS0000016929.V260960.R01.S.doc Version 5.0 Page 26 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
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