Inspection on 24/04/06 for 76 Holland Street

This inspection was carried out on 24th April 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 30 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

76 Holland Street 13/01/10

76 Holland Street 19/01/09

76 Holland Street 15/01/08

76 Holland Street 07/06/07

76 Holland Street 31/10/06

76 Holland Street 08/11/05

76 Holland Street 06/05/05

76 Holland Street 14/02/05

76 Holland Street 27/07/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Holland Street, 76 Sutton Coldfield West Midlands B72 1RR Lead Inspector Donna Ahern 24th April 2006 10.10 Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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 Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holland Street, 76 Address Sutton Coldfield West Midlands B72 1RR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 354 2789 0121 355 0832 Social Care and Health Gillian Charmaine Gayle Care Home 22 Category(ies) of Learning disability (21), Learning disability over registration, with number 65 years of age (1), Physical disability (21) of places Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That the home is registered for 21 adults under 65 and 1 service user over 65 The service users should all be in need of care for reasons of learning disability with associated physical disabilities Registration category will be 21(LD) (PD), 1 (LD)(E) Minimum day staffing levels are maintained at: morning - 6 care assistants and 1 senior, afternoon - 6 care assistants and one senior. Where off-site day care is provided for five or more service users, day staff levels can be reduced pro-rata between 09:00am and 4:00pm. Additionally to the above minimum staffing levels, at night 2 waking night care staff and a senior on sleeping-in duty Details of staffing numbers and deployment must be set out in the home’s Statement of Purpose. Care manager hours and ancillary staff should be provided in addition to care hours. A programme for planned maintenance and renewal is implemented by end of April 2004. By end September 2004 plans are agreed with the CSCI with stated timescales for the future re-provision of this service to ensure standards commensurate with fitness for purpose for the needs of the client group. That Gillian Gayle successfully undertakes the Registered Manager’s Award or equivalent by April 2006. That Gillian Gayle undertakes Challenging Behaviour Training by June 2006. 8th November 2005 5. 6. 7. 8. 9. 10. 11. Date of last inspection Brief Description of the Service: The home is a large two-storey building of modern design and appearance, set within its own grounds, occupying a corner position. The home is located in a residential road in Sutton Coldfield. The gardens at the rear of the home are spacious and secluded. There is parking facilities to the front and rear of the building. The home provides accommodation to 22 adults who have a learning disability; some have additional physical disabilities and behaviour that may challenge. Each resident has a single bedroom. The home is arranged over four units. Each unit has a kitchen and a lounge. Incorporated in the Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 5 accommodation for residents is a flat, which is occupied by two residents. The inspection raised concerns regarding the homes physical standards. The bathroom facilities require refurbishment and other areas of the home require attention as detailed in the main body of the report. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was Unannounced and took place over one long day. The inspector met all residents and time was spent observing care practices, interactions and support from staff. A tour of the building was made. Resident’s care plans and risk assessments were inspected. Staff training records were examined, and a number of Health and Safety records were inspected. The inspector spoke to the manager, assistant manager and four support workers. What the service does well: What has improved since the last inspection? What they could do better: There is still a lot of work that must be done to make this a safe and comfortable home for the people who live at Holland Street. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 7 The manager and staff must improve the care plans that they have developed for each resident. These must tell the staff how to support each person. They must be clear about what help and support each resident needs and what staff must do to support the individual. These must be kept up to date. The home must improve how it says it will help residents reduce some of the risks that they may face in the home or when they go out on an activity or independently access the community. The staff must improve the way that resident’s health needs are recorded, monitored and followed up. The Staff must start to do Health Action Plans with each individual. They must also keep up to date the support that residents need with their mobility. The staff and manager must look at how they can enable more of the resident’s to do more things for themselves like cooking and domestic jobs in the home. A lot of work was required to the building to make it a comfortable and safe place for residents. Many of the bedrooms need decorating and painting. The Provider must make sure that the bathrooms are suitable for all the residents and that they can safely get in and out of the bath. The Work Place Fire Risk assessment required updating. Medicine management required some further improvements so that residents are protected by the homes procedures and practice. Staff must do more training so that they have up to date knowledge and skills regarding the residents they support. The required information on staff who work in the home must be available (such as their previous experience and training) and evidence that all of the safety checks on their suitability to work in the home have been carried out before they start to work at the home. So that the provider can demonstrate their commitment to protect residents. 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. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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 Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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): 1, 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Information about the home must be developed so that it is available in suitable formats for the people who live at Holland Street. EVIDENCE: There have been no new admissions to the home since the previous inspection. Five residents had plans in place to move on to new homes this included registered homes and supported living. Residents spoken to indicated that they were looking forward to the moves. Two residents were due to move in the next few weeks and some moves were in the early stages of planning. The provider has indicated to CSCI that as residents are supported to move onto new living environments the number of registered beds will be reduced and no new admissions will be made. The Statement of Purpose and Service User Guide had been kept under review. The manager must explore how these documents can be provided in a format that is suitable for the people who live at Holland Street. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans required development so that a comprehensive plan is in place for each resident that details how residents assessed needs and goals will be met. EVIDENCE: The previous inspection raised that Care plans required development so that a comprehensive plan is in place for each residents that details how their assessed needs and goals will be met. The manager said in the action plan received 20th January 2006 that the home was to be part of a pilot scheme to improve resident information. This had not been actioned and the development of care plans and resident information remains outstanding. Three care plans were sampled. Care plan one was reviewed in August 2005 and should have been reviewed in February 2006. The review date had ceased with no evidence of a review taking place. The second care plan assessed was last reviewed 28/07/03 there had been significant changes in the persons care needs that had not been documented. It was positive that the manager had made a referral to the social work team to reassess the person’s needs, however it is imperative that care plans are kept under review. The third care Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 11 plan had been kept under review with the last review date of November 2005. This person had a review meeting on the day of the inspection. The previous report highlighted that it was positive the manager had implemented a system where the summary of the care plans was kept with resident’s daily notes as this provided some key information in an easy reference format. These were also in need of updating and review so that they reflect resident’s current needs. Daily records examined indicated that recordings are completed after each shift the records sampled gave information mainly about peoples personal care needs and limited information about residents response to care. The person completing the report must sign these recordings. Risk assessments were examined and significant development of these are required. Risk assessments must be implement in a number of areas that may pose a risk to individual residents. There were no risk assessments available regarding resident who are supported to develop their independence skills such as cooking and washing and household tasks. Limited risk assessments were in place for residents who access the community independently. Some of the “support protocols” that had been developed for individual residents had some good information but required further development so that there is evidence that the safeguards in place are adequate. Support protocols must cross reference to the relevant risk assessments. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The staff must improve opportunities and be able to evidence how they support residents to develop their independent living skills. EVIDENCE: Many of the residents attend a local day centre or college. On the first floor, which is referred to, as C wing there is a kitchen, which is used by the six people. The home refers to this part of the building as the minimum care unit. The inspection in May 2005 raised concern about the condition of this facility and questioned whether residents were receiving adequate support to develop their independent living skills. At the inspection in November 2005 improvements were noted to the cleanliness and organisation of this facility so that each resident who lives on this wing were supported with their independent living skills. However at this inspection concern was raised again about how residents are supported to develop their skills. Residents said that staff do the cooking and they help with shopping and cleaning tasks, this was confirmed by staff on duty. Many of the people are looking at moving on Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 13 to live in a more domestic style environment and are keen to live more independently but are not being supported to develop these required skills. Risk assessments to evidence that residents are supported to be independent within a risk assessment framework had not been actioned as required at the previous inspection. Cleaning schedules had not been completed or updated since February 2006 the information displayed was two months out of date. The practice in place contradicts what was reported to the inspection team at the announced inspection in November 2005. Some residents said that they enjoy going to Gateway club on a Monday night with support from staff. Residents said that they have good access to a range of shops, pubs and places to eat in Sutton Coldfield Town Centre, which is a short walk away. Some of the residents live fairly independent lifestyles and come and go as needed. Residents are asked to inform the manager on duty of when they are due to return as a precautionary safety measure. Residents said they can go to bed and get up when they want to. Residents were seen choosing to spend time in their own rooms and freely accessing the communal areas of the home. Residents said they are supported to maintain links with their family and friends. Some residents said that they visit and stay with their relatives on a regular basis. An evening meal was observed and residents were given appropriate support. Records of food served were examined these must include an accurate record of what residents have eaten. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements must be made to resident’s health care information so that the manager and staff can demonstrate that residents have received the medical and health input they require. EVIDENCE: Care plans indicated that residents are supported to attend a range of healthcare appointments. The previous report required that the recording of appointments and their outcome must be reviewed as some appointments were recorded on the healthcare log and the detail was cross-referenced to a daily record entry. Other appointments were recorded in with daily entries. Limited progress had been made on improving recordings. Medical and health information on the four sampled care plans was difficult to track. The implementation of health action plans remained outstanding. The manager stated that this work should commence soon and a community nurse will be supporting the home with the development of the Health Action Plans. Manual handling risk assessments sampled had not been kept under full review. The Manual handling needs on one of the case track files had not been reviewed since August 2003. Staff must sign to say they have read and will Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 15 follow the manual handling risk assessment these were seen to not reflect staff changes with ex staff names not deleted and new staff since 2003 not added to the staff signature sheet at the rear of the manual handling assessment. Risk assessments were required for all residents who use a wheel chair in the home and the community. The assessment must include the use of posture belts and in what circumstances these are used. Service details and manufactures details must be available for each wheelchair. Risk assessments required implementing for residents with epilepsy. The support required by residents during the night must be risk assessed and any support required from staff and how this must be given must be documented. This remains outstanding from the previous inspection. Previous reports have raised the need to review the needs of residents with additional physical disabilities, including their bedroom layout and their lifting and moving needs. Beds had been moved so that staff can support from both sides of the bed. The rooms are small and the new layout continues to present some challenges to the staff when assisting residents. The bedrooms are not adequate to meet the needs of a person with additional physical disabilities, they are cramped and there is no turning space. The manager said as residents move from Holland Street there should be the opportunity to make some of the bedrooms bigger. The manager said that a new blister pack medication system was implemented in January 2006. Medication is stored in locked cabinets on the ground and first floor. Not all the quantities of medicines received or balances carried over from previous cycles had been recorded so it could not be demonstrated that medicines had been administered correctly. A number of gaps were seen on the Medication Record Chart. The manager must commence staff drug audits so that errors can be identified and dealt with. One item of prescribed cream must be returned to the pharmacist. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are listened to and protected from abuse. EVIDENCE: The previous inspection required that some minor additions were made to the Adult Protection Procedure, so that there is clear information and relevant contact details available for staff to access and follow in the event of abuse being suspected or disclosed. This had been actioned. Residents said that if they are not happy about something they could talk to staff or the manager. The complaints log had been developed so that the outcome of complaints and any follow action had been documented. The manager had received no complaints about the home since the last inspection two compliments had been received from resident’s relatives. The organisation has a complaints procedure this must be produced in a format suitable for the people who live at Holland Street and the contact details must be updated to include the complaints divisions new address details. This must be displayed and made available to residents. The management of resident’s personal money was not fully assessed at this inspection. Protocols had been implemented for supporting residents when they withdraw money from the cash point these must be underpinned with a risk assessment. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The home is not comfortable and homely. EVIDENCE: Previous reports have raised concern regarding the physical standards of the home. The home is not suitable for the purpose of achieving its stated aims and objectives. Painting and decorating was required throughout the home. Areas where there is damp coming through required attention to the plaster and décor. Bathrooms require refurbishment. There is a lack of space in the bedrooms that accommodate residents with additional physical disabilities. This matter is also raised under standard 18. Some of the rooms have dividing partitions. The sound proofing between these bedrooms is inadequate and it was felt that they compromise the privacy of the residents who occupy these rooms. The manager stated that decoration of the communal areas will commence shortly and some refurbishment of the bathrooms will also take place. The shower that was not in use at the time of the previous inspection had been repaired and was fully operational. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 18 The manager said that as residents move on to alternative homes registered numbers would reduce which will provide some flexibility for the use of bedrooms. She was exploring the possibility of some single bedrooms being knocked through to provide larger bedrooms particularly for residents with additional physical disabilities. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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, 34, 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Staff are not well supervised and have not received the required training to enable them to meet residents needs. EVIDENCE: Staffing levels are a condition of registration. The home is required to have six support workers and a senior on each shift. At night there is two waking night staff on duty and a manager undertakes a sleep in shift to provide on call support. A letter of serious concern was sent to the provider following the inspection in November 2005 requiring the provider to maintain minimum staffing levels. The required level of staff were on duty. Examination of the rota indicated that minimum staffing levels were being maintained and systems were in place to monitor the balance of permanent staff and agency staff on each shift. Staff Files had been reorganised so that information was easier to access. Four files were assessed and did not contain the required information. There was no application form on one file. CRB checks for two staff were outstanding, references were not available for one person and induction information was not available for two staff. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 20 Staff’s training records were poor and required trailing through to identify training achieved and training required. A training matrix was not available. Training dates, the duration of the training, training provider and when updates are required must be clearly documented. Sampled records indicated that formal supervision of staff takes place on an infrequent basis. Of the four files sampled two staff had not received supervision for six months and one staff members file indicated that they had not received supervision for eighteen months. Staff must receive a minimum of six supervisions a year so that they receive the support and supervision they need to carry out their job. Interactions between residents and staff were generally positive. Staff were seen to take time to talk to residents on a one to one. Residents said staff are friendly and helpful. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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, 39, 42, 43 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Health and Safety practices do not ensure that resident’s welfare and safety is protected. EVIDENCE: The manager’s post at Holland Street had been vacant for a protracted period. An acting manager has been in post since April 2005 and was appointed as the registered manager in December 2005. The deputy manager’s post remained vacant. The deputy manager position needs appointing to so that the management team can address the outstanding development matters. The manager was in the process of completing the level 4 N.V.Q and then will complete the registered managers award. Residents and staff made positive comments about the management style of the home. Staff felt that improvements had been made and said that the manager is very approachable. Residents said that house meetings are held and that the staff and the manager ask their views about the home. Residents Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 22 said that they could speak to the manager when they need to. The manager has instigated regular meetings with resident’s relatives to review how the home is meeting their relative’s needs. Action plans to previous inspection were not received within the required timescale and missed the date deadline for the report going final. The manager was very open to the inspection process. There was evidence of some improvements to systems to monitor practice however considerable development of staff training and development is required so that the manager can evidence that staff have the skills and knowledge to meet residents assessed needs. Risk assessments regarding residents, their health care records and residents care plans required further development so that the provider can evidence that their needs and changing needs are kept under review. A number of Health and Safety records were examined. An immediate requirement was made to undertake weekly test of the fire alarm and monthly test of the emergency lights. Examination of the fire records identified that these tests were not undertaken as required. A fire drill was required and staff training on fire safety matters. The Work Place Fire risk assessment required review. Random testing of water temperatures had not been completed since 5th March 2006. Where the provider is an organisation they are required to nominate someone to carry out unannounced visits to the home and carry out interviews with residents, their representatives and persons working at the home. A written report on the conduct of the home must be produced and a copy available at the home for inspection. Examination of the reports available in the home indicated that such visits had not been undertaken monthly as required (evidence of most recent visit November 2005). The owner’s representative must evidence that such visits have been undertaken in accordance with the regulations and that they are fulfilling their responsibility to oversee the overall management of the home. Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 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 Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 3 X X 2 1 Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5 (1) (2) Requirement The Service User Guide must be produced in a suitable accessible format for residents. Care plans required further development. They must be clear and specific about the support required by residents and kept under review. Previous Requirement 28/2/06 Risk assessments must be further developed. They must be clear and specific about what the risks are. They must be kept under review. Previous requirement 31/12/05 Residents must be offered a choice of activities. The range and choice of activities must be kept under review. The Provider must promote opportunities for residents to develop their independent living skills. Timescale for action 31/07/06 2. YA6 15 (1) (2) 31/07/06 3. YA9 13 (4) a, b, c 31/07/06 4. YA12 16 (2) (m) 30/06/06 5. YA11 12 (1) (a) 15 (1) 31/12/06 Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 25 6 YA17 16 (2) G 7. YA17 8. YA18 9. YA18 10 YA18 11. YA19 12. YA19 13. YA19 14. YA20 Fridge and Freezer temperature be monitored and records kept of the tests. 16 (2) (I) Records of food must include an accurate record of what residents have eaten. 13 (5) Manual handling risk assessments required further development. They must be kept under review. Previous requirement 31/12/06 13 (4) a, b, c The support residents require during the night must be risk assessed. Previous requirement 31/12/05 13 (4) Risk assessments must be implemented for residents who use wheelchairs and the use of posture and lap belts. 12 (1) a Health care recording must be improved. Previous timescale 30/06/05 12 (1) a 13 (4) Risk assessments were required for residents with epilepsy. Previous requirement 30/11/05 12 (1) a Health Action Plans must be implemented for all residents. Previous requirement 28/02/06 13(2)17(1)aSch3(3)i The quantity of medicines received into the home or the balances carried over from previous cycles must be accurately recorded to enable audits to take place to demonstrate that the medicines have DS0000033648.V290035.R01.S.doc 01/05/06 31/05/06 30/06/06 30/06/06 30/06/06 31/07/06 30/06/06 31/08/06 25/04/06 Holland Street, 76 Version 5.1 Page 26 15. YA20 13(2) 16 YA20 13 (2) 17 YA22 22 (2) 18. 19. 20. YA24 YA24 YA24 23 (2) (d) 23 (2) (d) 23 (2) (d) 21. YA24 23 (2) (b) 22. 23. YA33 YA34 18 (1) a 7,9,19 Sch 2 24 YA35 18 (1) (a, c) been administered as prescribed. Regular staff drug audits before and after a drug round must be undertaken by the manager to demonstrate staff competence in medicine management. Appropriate action must be taken when discrepancies are found. Medication Record sheets must be signed when medication is administered. The complaints procedure must be made available in a format suitable to residents and made available to all residents. The ceiling on C wing was damp and peeling and required repainting. Paintwork throughout the home required attention. The damp on the wall in the hallway required attention and the paper repaired. A planned maintenance and renewal Programme for the building is required. Vacant posts must be appointed to. The home must have on each staff file all of the information as detailed in schedule 2 of the National Minimum Standards for Younger Adults. Not assessed previous requirement carried over. Staff must receive training in Challenging DS0000033648.V290035.R01.S.doc 09/12/06 25/04/06 30/06/06 31/12/06 31/12/06 31/12/06 21/11/06 25/04/06 25/04/06 25/04/06 Page 27 Holland Street, 76 Version 5.1 Behaviour. Adult Protection. First Aid Manual Handling Epilepsy Person Centred Planning. A training plan and matrix is required. Staff must receive regular supervision at least six per year with records kept. The work place Fire Risk assessment required review. The weekly testing of the fire alarm must be undertaken as required with written evidence that the checks have been actioned. Emergency lights must be tested monthly. Random testing of water outlets must recommence. A representative from Social care and Health must visit the home unannounced on a monthly basis. Reports of the visits must be available in the home. Copies of the report must be forwarded to CSCI. Previous requirement 15/3/05 25 YA36 18 (2) 31/12/06 26 27 YA42 YA42 23 (4) 13 (4) 23 (4) C (V) 30/11/06 01/05/06 28 29 30. YA42 YA42 YA43 23 (4) C (V) 13 (4) 26 30/04/06 26/04/06 31/12/06 Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holland Street, 76 DS0000033648.V290035.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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