Inspection on 12/10/05 for 35 Hawthorn Road

This inspection was carried out on 12th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

35 Hawthorn Road 17/08/06

35 Hawthorn Road 09/02/06

35 Hawthorn Road 21/03/05

35 Hawthorn Road 04/08/04

35 Hawthorn Road 23/01/04

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Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

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10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hawthorn Road 35 Hawthorn Road Erdington Birmingham B44 8QS Lead Inspector Kerry Coulter Announced 12 October 2005 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. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hawthorn Road Address 35 Hawthorn Road Erdington Birmingham B44 8QS 0121 384 2228 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) Sense West Vacant Care Home 5 Category(ies) of Learning Disability - Sensory Impairment (5) registration, with number of places Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Minimum of 3 suitably qualified staff on duty, as well as the care manager, from 7.30am - 10.00pm. 2. An additional member of care staff provided for six hours across the day. 3. All residents must be under 65 years of age. Date of last inspection 21 March 2005 Brief Description of the Service: Hawthorn Road is a care home owned by Sense, who provides services to people who are deaf, blind and have associated disabilities. Hawthorn Road was first registered in December 2002, it is a traditional house, which was purpose designed to meet the needs of people with visual and hearing impairments and associated learning and communication difficulties. Hawthorn Road is currently home to five people with an age range from early thirties to mid forties. On the ground floor there is a communal lounge, a quiet sitting room and a dining room. There is a staff office, toilet and a laundry. One of the bedrooms is on the ground floor. On the first floor there is a further four bedrooms all with ensuite facilities. The home does not have a lift, so only ground floor accommodation is accessible to someone with mobility needs. To the rear of the house there is a large garden with mainly grassed area and a patio. The garden also has a brick built sun house, which has the potential to be used as additional space for service users. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and was carried out over six hours. This was the first of the statutory inspections for this home for 2005/2006. During the inspection a tour of the premises was made, service user and staff files were sampled as well as other care and health and safety records. The Inspector spoke with the Manager and members of staff and met with all of the service users. Conversations with service users were limited due to their complex needs and limited verbal communication abilities. Information has also been obtained from the pre inspection questionnaire. CSCI comment cards have been received from relatives, care managers and health and social care professionals. What the service does well: What has improved since the last inspection? Previous inspections have highlighted the need for the standard of the recording in service user daily records to improve. The Manager has shared with staff the expected standard. Sampled daily records at this inspection showed that improvements have been made. One service user has received input from the Continence Advisor, following some hard work from staff they have been successful in eliminating the need for the service user to wear incontinence pads. It was identified at the last inspection that en-suites were not personalised in style. This has been done with the addition of pictures. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 6 At the last inspection the home had many vacant staff positions. Some new staff have now commenced work and vacancies have been reduced. This ensures service users are usually supported by staff who know them well. 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. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 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 Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 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 The Statement of Purpose and Service User Guide provide most of the information needed about services provided, and this is reinforced by assessment and admission procedures. EVIDENCE: The home’s Statement of Purpose has recently been updated, a copy was sent to the CSCI prior to the inspection and was observed to contain the required information. A new Service User Guide has also been developed to replace the old version. This was received by the home on the day of the inspection in a CD Rom format that included pictures of the home. Consideration should also be given to the use of video or audio as suitable to individual need. There have been no changes to the service users group since the last inspection. All of the current service users relocated from other Sense homes and moved to the home when it opened in December 2002. A referral and admission policy is available and a summary of the admission process is included in the statement of purpose. SENSE benefits from having the services of a Referral and Information Manager who receives any initial referrals, an assessment would then be completed by the Manager. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 There is a clear and consistent care planning system in place to provide staff with information they need to meet service user needs. The systems for service user consultation are generally good with a variety of evidence that indicates service users views are sought and acted upon. Strategies for managing risks were generally clearly identified with only minor improvement required to ensure risk is effectively managed. EVIDENCE: The care records for two service users were sampled. Care plans sampled were up to date. These were found to be comprehensive documents. They include information on personal profiles, past history, information you need to know, communication and care routines. In addition, some service users have individual support strategies and guidelines, in some cases devised by professionals working in partnership with staff in the home. Core team reviews take place on a regular basis, generally monthly. Records show that areas such as care plans, activities, health and behaviour monitoring are covered at these meetings. A care plan review meeting is also arranged annually, social workers, relatives or advocates are invited to attend as appropriate. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 10 Previous inspections have highlighted the need for the standard of the recording in service user daily records to improve. Sampled staff meeting minutes show that the Manager has shared with staff the expected standard. Sampled daily records at this inspection showed that improvements have been made. Records evidenced that choice is offered to service users, this included times of going to bed and getting up, what to wear and choice of activities. Members of staff actively encourage each service user 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. All of the service users have very complex needs and their involvement in the day to day running of the home is limited, however observations at the time of the visit indicated that service users are encouraged to be involved in daily tasks including, removing dishes to the kitchen, making themselves a drink, bringing their washing to the laundry. A wide range of risk assessments were observed to be available for each individual. The assessment for two service users were sampled, these included fire evacuation, bathing, night monitoring, swimming, making a hot drink and self injurious behaviour. Care plans are cross referenced to the risk assessments so that the reader is naturally directed from one to the other. The majority of service user risk assessments had not been reviewed in the last six months, these will need to done to ensure the control measures in place are still appropriate. The level of risk also needs to be made clearer within some assessments. Discussion with the Manager indicates that the Acting Deputy is soon to go on risk assessment training, this will then mean that the Manager can share the responsibility of completing and reviewing assessments. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16, 17 Intergration within the community and pursuit of leisure activities are integral elements of the ethos of the home. Staff support service users to maintain and develop relationships with family and advocates. Dietary needs of service users are well catered for with a balanced and varied selection of food available. EVIDENCE: The care plans contained a “Schedule of activity”. Activities on offer include the cinema, cooking, rock climbing, ice skating, music, horse riding and massage. On the day of the inspection service users were involved in out of house activities to include shop and cook and swimming. The home has a car and a people carrier to assist with accessing community opportunities. Where possible local community facilities are accessed such as local shops, swimming pool, library and hairdressers. Within the home service users have access to activities including tactile objects, sensory equipment and music. To the rear of the home there is a large garden with seating. Service users also have the opportunity to have an annual holiday. A planned holiday for one service user is to Devon. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 12 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. Staff said that one service user had also been on holiday to Wales this year and was able to meet with relatives whilst there. It is an area of good practice that SENSE employs a Family Liaison Officer. Additionally, an annual family weekend is also arranged at a local hotel where relatives can meet with SENSE representatives and other relatives. One service user does not have any family input but has an advocate who is invited to care plan review meetings. Two comment cards were received from relatives/ advocates, these did not record any concerns about the care practice in the home. Observations at the time of the inspection indicated that service users are free to access all parts of the home as they wish. Service users have been enabled to use their mapping skills and at the time of the inspection they moved around the house with confidence. The menus inspected showed that the food was varied, wholesome and nutritious. Some service users are receiving input from the dietician to assist with weight reduction. Food stocks were satisfactory. The food actually eaten is recorded in detail in the daily records. People who live at the home assist in the shopping for food. Service users were observed being assisted to prepare their own breakfast and were able to eat at flexible times depending on when they got up in the morning. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Generally the healthcare recording and monitoring systems evidence that the service user needs are properly monitored and kept under review but a dental appointment for one individual required following up. The medication system is generally satisfactory but the transcribing of medications onto the Medication Administration Record require improvement to ensure service users receive the medication they need. EVIDENCE: Care plans sampled had good detail in respect of service users personal care routines. At the previous inspection the Manager was awaiting the report from the Occupational Therapist with recommendations for the en-suite bathroom of one service user. The report has now been received and a capital bid for funding has been made for the recommended work to be done. One service user has received input from the Continence Advisor, following some hard work from staff they have been successful in eliminating the need for the service user to wear incontinence pads. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 14 Care plans sampled indicated that a range of health professionals are involved in the service users care. Health Action Planning has been introduced recently. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. The Manager has recently written to the GP to request health checks for service users, following this the GP has responded by agreeing to undertake medication reviews. The health action plan for one service user recorded that their planned dental appointment in March had been cancelled. However it was unclear what action, if any had been taken to rebook the appointment. The Manager agreed to follow this up. The system for the administration of medication is generally satisfactory. Medicines were seen to be stored appropriately in a secure location. A random audit of stocks held revealed no discrepancies, and there were no gaps on the administration record. Creams were observed. These had been dated when opened. FP10 prescriptions had been copied. It is good practice that clear descriptions have been completed on how service users prefer to take their medication. There is some concern regarding the standard of transcribing of medications onto the Medication Administration Record (MAR) by staff, when the chemist had not undertaken this. This process was not robust, and must be reviewed as some medications did not have clear directions of quantity and frequency prescribed. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The home has a satisfactory complaints procedure but alternative formats need to be considered. Some physical intervention recording is lacking and may impact on the homes ability to ensure that service users are being protected from abuse and that their welfare is being promoted. EVIDENCE: The organisation, Sense, has produced a policy, referred to as ‘issues policy ’in respect of complaints. This was assessed as meeting the required standard at the last inspection in March 2005. The Manager said that no complaints had been received since the last inspection. All of the service users at Hawthorn Road are very dependant on staff interpreting/facilitating any concerns /complaints that they may have. At the last inspection the inspector was informed that the home was in the process of producing the complaint procedure in alternative formats to the written version that are more suitable/accessible for service users, this has yet to be done. The home/organisation has a detailed Adult Protection policy and the Birmingham Multi Agency guidelines were also available. Staff at the home have received training in adult protection and staff records sampled show that robust recruitment procedures had been followed. Records on the use of physical intervention were sampled. Most records were very detailed but some did not record the length of the intervention. One incident of physical intervention had not had a physical intervention record completed. Not all incidents of physical intervention had been notified to the CSCI as required. Records on the use of physical intervention require improvement to ensure they meet the Department of Health guidance for restrictive physical interventions (2002) and to show that service users are not subject to unnecessary intervention. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28, 29, 30 The standard of the environment within this home is good providing service users with an attractive and homely place to live. One service user does not have the right equipment to enable them to have a bath but in general most service users are provided with the specialist equipment they need. EVIDENCE: Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 17 35 Hawthorn Road is a traditional built house that has been adapted to meet the needs of service users. All service users have single bedrooms with ensuite. It was identified at the last inspection that en-suites were not personalised in style. This has done with the addition of pictures. One service user has both a shower and a bath. The Occupational Therapist has recommended that a different type of bath is required. The Manager has applied for funding for this to take place but has yet to hear if the funding has been agreed. Discussion with the Manager indicates that the service user prefers a bath to a shower. The bedrooms were all observed to be comfortable and personalized. Some of the bedrooms have double beds for extra comfort. A variety of seating is provided in service uses bedrooms including sofa, comfy chair or beanbag according to the staff’s interpretation of the service users preference. The home has a range of communal space for service users use, including a good-sized domestic style kitchen, separate dining room and two lounges. However one of the lounges is used mainly by one service user who likes their own space. To the rear of the home there is a very large garden with a patio area and a large grass area with a covered pond. There is a brick sun house in the garden. One comment card from a relative recorded that they would like somewhere private to meet with the service user, this needs to be considered. Perhaps with the addition of heating and electricity the sun house could be utilised for this purpose. Around the home there are tactile indicators to indicate to service users where doors, stairs and other hazards are. The lounges, dining areas and kitchens also have tactile indicators. Systems are also in place to alert the service users to someone entering the room, for example via a fan switching on. The home was found to be clean, hygienic and free from offensive odours at the time of the inspection. Liquid soap and paper towels were available for hand washing. The laundry is accessed off the main hallway and there is direct access to the garden where there is a rotary washing line. The home has a sluice cycle washing machine. Food stored in the fridge was date labelled to reduce the risk of service users from getting food poisoning. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35, 36 The staffing arrangements ensure service users are supported by sufficient numbers of knowledgeable staff to meet their needs. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company, staff give support with warmth, friendliness and patience and treat people respectfully. Staffing levels are a condition of registration and the home was found to be meeting these conditions of registration. At the last inspection the home had many vacant staff positions. Some new staff have now commenced work and vacancies have been reduced. There is still some use of agency staff to cover remaining vacancies and some long term staff absences but the staffing situation is much improved. Recent regulation 26 monthly reports from the representative of SENSE visiting the home record that staff morale is much improved since the reduction in staff vacancies. The files of two members of staff was sampled. This had details of the application form, references, CRB/POVA check and identification details to evidence that residents are protected by the homes robust recruitment procedures. Information was also available to show that agency staff had CRB checks. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 19 A training matrix was provided as part of the pre inspection questionnaire. Along with staff supervision records this indicates that a rolling programme of training and updates are provided. New staff have received training in adult protection and challenging behaviour. Some are undertaking British Sign Language via a bursary scheme. It has previously been identified that SENSE as an organisation did not provide staff with the opportunity to undertake the Learning Disability Award Framework (LDAF). Progress has been made on this and a pilot scheme is now underway. Due to the home having several new staff in post only 33 have an NVQ in care, however staff are enrolled on NVQ and so this figure should rise in the future. Staff are given satisfactory levels of supervision to enable them to carry out their role effectively. Supervision records were well organised with clear action points arising from each session. Formal supervision takes place with regular agency staff as well as SENSE staff. Regular staff meetings take place and records are maintained of these meetings. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41, 42 The service users benefit from a well run home. Systems are in place to promote the health and safety of service users. EVIDENCE: The home has not had a registered manager since October 2003. The Manager currently in post has submitted an application to become the registered manager. The application received indicates that the Manager has several years experience of working with people who have a learning disability and sensory impairment. A member of staff stated they felt they could approach the Manager with any concerns. Systems are in place to measure the quality of the service the home provides. This includes monthly visits to the home by the general manager who completes a report and forwards this to the CSCI. Audits are carried out periodically to include the staff files by personnel. Additionally, part of the role of the Practice Development Worker is to complete quality assurance audits, this includes the level of activities on offer. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 21 Records that pertain to individual service users were well maintained, structured and stored securely. Records relating to staff were also stored appropriately. The organised system was of benefit to the inspection process as the Manager was able to supply the Inspector with requested records speedily. Service users and staff generally have their health and safety promoted by the procedures in the home. Regular health and safety audits are completed. Records evidenced the regular testing and servicing of fire alarms. Equipment in the home is regularly serviced. COSHH items were observed to be securely stored. Up to date detailed risk assessments for the premises, risk of fire, staff and food had been completed. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 2 3 2 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 4 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hawthorn Road Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x 3 3 x E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 23 No 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 9 Regulation 13(4) Requirement Service user risk assessments must be reviewed at least six monthly or sooner if a critical incident occurs. The risk assessment must clearly record the level of risk. Ensure that the cancelled dental appointment for one service user is rebooked and the health action plan records the action taken. The standard of transcribing of medications onto the Medication Administration Record (MAR) by staff, when the chemist has not undertaken this must be improved. The process of completing and making available the complaints procedure in alternative formats needs to be completed. Accidents/incidents to include the use of physical intervention must be notified to CSCI. Records on the use of physical intervention require improvement to ensure they meet the Department of Health guidance for restrictive physical interventions (2002). Timescale for action 30/11/05 2. 19 12(1)(2) & 13(2) 30/11/05 3. 20 13(2) 14/10/05 4. 22 22 30/12/05 5. 6. 23 23 12(1) 13(6) 12(1) 13(6) 13/10/05 30/11/05 Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 24 7. 27 & 29 23(2)(j, n) Action plan required regarding the provision of a suitable bath for one service user to meet the recommendations of the Occupational Therapist. 30/11/05 8. 9. 10. 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 28 Good Practice Recommendations Consideration needs to be given to providing visitors with a private area in which to meet their relative. Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hawthorn Road E54 S30424 Hawthorn Road V246227 121005 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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