Inspection on 06/05/05 for 76 Holland Street

This inspection was carried out on 6th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 42 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 24/04/06

76 Holland Street 08/11/05

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) 76 Holland Street Sutton Coldfield Birmingham B72 1RR Lead Inspector Donna Ahern Unannounced 6 & 10th May 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holland Street (76) Address 76 Holland Street Sutton Coldfield Birmingham B72 1RR 0121 354 2789 0121 355 0832 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) Social Care & Health (Birmingham & Yardley Area Office) Vacant Care Home 22 Category(ies) of Young Adults (18 - 65) registration, with number of places Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 That the home is registered for 21 adults under 65 and 1 Service User over 65. 2. The Service Users should all be in need of care for reasons of Learning Disability with assoicated Physically Disability 3. Registration category with be 21(LD)(PD) 1(LD)(E) 4. Minimum day staffing levels are maintained at morning 6 Care Assistants and 1 Senior, Afternoon 6 Care Assistants and 1 Senior. Where off-site day care is provided for 5 or more Service users day staff levels can be reduced pro-rata between 09.00 and 16 00 hrs. 5. Additional to the above minimum staffing levels at nights 2 waking staff and a senior on sleeping in duty. 6. Details of staffing numbers and deployment must be set out in the homes Statement of Purpose. 7. Care Manager hours and ancilliary staff should be provided in additional to care hours. 8. A programme for planned maintenance and renewal is implemented by end of April 2004. 9. By end of September 2004, plans are agreed with CSCI with stated timescales for the future reprovision of this services to ensure commensurate with fitness for purpose for the needs of the client group. Date of last inspection 14th February 2005 Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 5 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 accommodation for residents is a flat which is occopied by two residents. The inspection raised concerns regarding the homes physical standards. The bathroom facilities are in a poor condition and other areas of the home require attention as detailed in the main body of the report. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The inspector met nine residents and time was spent observing care practices, interactions and support from staff. A tour of the building was made. Residents care plans and risk assessments were inspected. Staff training and recruitment procedures were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the manager and four of the support workers. What the service does well: What has improved since the last inspection? What they could do better: Not much progress had been made on previously raised requirements. A lot of work must be done to make this a safe and comfortable home for the people who live at Holland Street. The home must improve the care plans that they have on each resident. These tell the staff how to support each person. They must be clear about what help and support each resident needs and what the 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. The home had a lot of vacant posts for care staff. Sometimes there is not enough staff on duty. This should not happen. Holland Street is a large home and a lot of the people need a lot of staff support at meal times and with their personal care. When the inspector walked around the home in the early evening there was no staff visible in any of the communal areas of the home. The home must have six care staff on shift and a senior when all the residents are at home. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 7 The home must improve the range of activities that all residents can take part in. They must record what each person has done and keep records of what they have enjoyed. The home must improve the way that resident’s health needs are recorded and followed up. The home must start to do Health Action Plans with each individual. The home required a lot of work to make it a safe and comfortable place for residents. One shower room was locked and out of use. The specialist bath that is used for people with physical disabilities was out of use and residents said that another bath (that is in use) is difficult to get into. Lots of areas in the home required general repair work. A lot of the communal areas were very bare in appearance. The home must improve the records it keeps on some of the Health and Safety checks such as fire drills and water temperature checks. Staff must do more training so that they are up to date with their knowledge. The home must keep a record of the training that staff have completed. 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) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 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 standard(s) Not assessed at this inspection. EVIDENCE: Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 Care plans and risk assessments required development and had not been kept under review. These shortfalls are of concern and have the potential to cause inconsistencies in the care and support given to residents. EVIDENCE: Four residents care plans were examined. As raised in previous inspection reports the files were seen to contain a lot of information that should be archived. Some work on Person Centred Planning had taken place. The individual Service statements (ISS) that were on file require review. One had not been reviewed for fourteen months. Care documents examined had not been signed by any of the resident’s representatives. Daily records examined were of a poor quality. They were repetitive and did not include the resident’s response to care given or evidence of choices that the resident had made. On one of the four care plans examined there were guidelines in place for the management of behaviour (dated17.2.03) there was no evidence that they had been reviewed. It was unclear how recommendation and advice from other professionals are incorporated into the residents care plan and monitored. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 11 The temporary manager was in the process of implementing a system that should enable a link to take place between the daily records and the monitoring of residents objectives as identified on their care plan (I.S.S). This was clearly required and progress will be monitored at future inspection to the home. The temporary manager was also in the process of re-establishing a keyworker system within the home and clarifying the purpose and value of this role. The home was not able to locate the risk assessments. On a return visit to the home three days later to complete the inspection the risk assessments had still not been located. When the deputy manager returned from his days off, the risk assessments were located. Some risk assessments were forwarded to CSCI for examination. These required further development. Risk assessments must be clear and specific about what the risk are and they must be kept under review. The risk assessments must cross reference to the care plan. It was unacceptable that staff and managers in the home where not able to access the risk assessments. These should be active documents that are referred to on a daily basis and must be readily available to all staff. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,and 16 Routines in the home were relaxed and resident’s rights were respected. The home must improve and be able to evidence how they support residents to develop their independent living skills. EVIDENCE: The home had a domestic kitchen, on the ground floor. Residents were observed accessing this facility. One of the residents said that they use the kitchen at night to get their own supper which is usually a drink and a sandwich and that they also help out with the washing up after meals. The kitchen had four sinks; two had been adapted for residents who use a wheelchair. On the first floor, which is referred to, as C wing there is another kitchen, which is used by the six residents who live on this floor. The home refers to this part of the home as the minimum care unit. One of the residents on this unit was putting their own ironing away. In the kitchen on C wing there were details of a residents cleaning and cooking rota, which involved the residents on a rota basis. The kitchen cleaning and checklist was a week out of date and the condition of the kitchen was poor. Food items opened and in the fridge were not dated or labelled. The kitchen cupboards work surfaces and the fridge was dirty. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 13 The home has facilities in the home, which provide opportunities for residents to develop their independent living skills. However attention was required to how residents are supported by staff to use these facilities. Many of the residents attend a local day centre and or college. Three of the residents spoken to said they enjoy going out in the evening or at weekends. One resident said she went for a drink at the local pub at the weekend. One resident said they like to go out to the shops. Three residents said that sometimes there is not enough staff on duty so they cant go out. Some of the residents go out independently. The documentation available on residents care plans and daily records was insufficient regarding activities they are involved in. It was not always possible to ascertain what people had been enabled to do and their response to activities or opportunities. The home had not undertaken appropriate risk assessments to evident that residents are supported to take risks as part of an independent lifestyle. Residents said that they had taken part in the election on the 5.5.05 and some had sent postal votes. Residents had keys to their rooms; one resident had a coded lock on their bedroom door this was said to be their preference. The morning routine was busy residents were supported with their personal care needs before going to the day centres. Residents came into the dining area on the ground floor for breakfast. Some residents came through in their dressing gown and some residents choose to have breakfast after they had a wash and had got dressed for the Day Centre or College. Residents came in and out of the dining area freely. The atmosphere was friendly and interactions between residents and staff were very positive. Staff communicated well with each other and would inform their colleague if they needed to leave the area to support a resident. There was always a staff member present to support residents in the dining area. However later in the day (16.30hrs) when walking around the home there was no staff available in the communal areas (lounges, dining room, kitchens) throughout the home on both the ground and first floor. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 Further development of the homes personal and healthcare recording and monitoring systems was required so that the home can evidence that resident’s needs are properly monitored and kept under review. EVIDENCE: Residents care plans indicated that they are supported to attend a range of healthcare appointments. A healthcare log was on the care plan however; this gave no detail of the outcome of the appointment and any required monitoring or follow up. The home must implement Health Action Plans for all residents (Department of Health Guidelines). Manual handling risk assessments had been completed however these had not been kept under review. Some of the assessments had not been reviewed since February 2004. The condition of the shower rooms and bathrooms were poor, the specialist bath was out of use and one bath was difficult to access because it is so low. These concerns are raised in more detail in the “environment section” of the report. An Occupational therapy assessment to assess the suitability of bathroom facilities for residents was required. It was unclear from reading residents care plans how advice from other professionals such as the physiotherapists was implemented into the care plan format. The temporary manager was in the process of re-establishing a keyworker system within the home and clarifying the purpose and value of this role. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 15 The homes arrangements for the recording, administration, storage, handling and disposal of medication were not examined at this inspection. The CSCI pharmacy inspector undertook audits of the homes medication systems and procedures in November 2004 and March 2005. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Some development of both the Adult protection Policy and the Complaints policy was required to ensure that individuals are fully safeguarded. EVIDENCE: The home had a detailed Adult Protection Policy and Procedure. Some minor development was required so that clear information and relevant contact details are available for staff to access and follow in the event of abuse suspected or disclosed. The home’s complaints log required some further development so that the outcome of complaints and any follow up is clearly documented. It was positive to read the compliments that the home had received from some relatives regarding the home. The service manager said that some staff had received training in Adult Protection matters in March 2005. This must be recorded on the home’s training record. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,26,27and 30 Many parts of the home were in a poor condition and required repair and refurbishment. The home is not suitable for the purpose of achieving its stated aims and objectives. EVIDENCE: A number of physical standard matters were identified. The bathrooms were in a poor condition. The bathroom on A wing had several broken tiles; several broken ceiling panels and the specialist bath was taped up with an out of use sign on display. The bath had been out of order for several weeks. The shower curtain had mould on it and required replacement. The boxing in of pipe work had become loose and required securing. The toilet in A wing had no plug in the sink and the water temperature was very hot and required regulating so that it does not present a safety hazard to residents (43-45 degrees). The tiles in the bathroom on B wing required resealing around the bath. The bath on C wing required resealing. The ceiling in the shower room was damp and was peeling and required repainting. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 18 The bathroom on D wing had a very low bath. The residents said that they have great difficulty getting in and out of the bath. The shower room was locked and had a notice stating the shower was out of order. The notice was dated 23.9.04 Paintwork throughout the home was in need of repair and painting. There was evidence in places that staff had tried to improve things by touching up the paper and paintwork. Light fittings throughout the home require auditing several were not working. Extractor fans throughout the home required cleaning. The kitchen on C wing required cleaning throughout. In the hallway there was an area of damp on the wall and the paper was peeling. Carpets required cleaning in areas. The carpet leading to bathroom A was damp and fraying at the door entrance. Communal areas were very bare in appearance and lacked personal items. Some bedrooms were inspected. These were seen to vary in size. One of the bedrooms for a resident who has additional physical disabilities had a poor lay out. The bed was against a radiator and usable space for turning and transferring was limited. Bedrooms did not have an adequate number of electrical sockets. Extension plugs with different appliances attached were in use. This practice must be reviewed. All bedrooms must be audited against the National Minimum Standards for Younger Adults and any shortfalls must be provided or if not appropriate, or not required by the resident this must be documented in residents care plan and kept under review. A condition of the homes registration was that a programme for planned maintenance and renewal was implemented by end of April 2004 and by the end of September 2004, plans should of been agreed with CSCI with stated timescales for the future reprovision of this service to ensure commensurate with fitness for purpose for the needs of the client group. Both of these timescales have lapsed and these conditions of registration remain outstanding. A requirement of the inspection was that the organisation respond formally to these matters. A breach of condition may result in the commission taking further action. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35 and 36 Staffing arrangements and recruitment practices are at times failing to meet the needs of residents. Staff required training updates and staff supervision was inconsistent. EVIDENCE: Staffing levels are a condition of registration. The home is required to have six support workers and a senior on each shift. The required level of staff was on duty at the time of the unannounced inspection, however examination of the rota indicated that the home continues to experiences difficulties meeting these levels. The home had kept written details of days when staffing levels had dropped. A risk assessment must be implemented which outlines the strategies that are in place when staffing levels fall below the required minimum. The service manager for the home who was present for part of the inspection stated that there are 201 care hours vacant and a senior support worker post vacant. The home must continue to notify CSCI when they drop below the minimum staffing level. CSCI will continue to monitor the situation. A breach of condition may result in the commission taking further action. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 20 The files of four staff were sampled. These required organising so that information is accessible. Two files had uncompleted induction forms which should be completed for new starters in their probationary period. Staff. Recruitment information including application forms and references were available however, there must be a recent photograph of staff on each file. Staff training details had not been kept up to date some had not been updated since 2000. This was of concern as it was not possible to ascertain what training staff had completed and what required updating. A training needs assessment must be carried out for the staff team and details of this must be forwarded to CSCI. The frequency of staff supervision was inconsistent. One staff member had received eight supervisions in a year and one person had received two sessions. Additional staff files examined identified major inconsistencies in the frequency of supervision dependent on which manager was responsible for the staff member’s supervision. Staff must receive the support and supervision they require to carry out their jobs. Recorded supervision must take place at least six times per year with records kept. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 42 The management arrangements for this home do not ensure that the Health, Safety and Welfare of residents are fully promoted and protected. EVIDENCE: The registered manager position was vacant. The home has had a number of management changes. A temporary manager had been in post since 4th April 2005;the home also had a temporary deputy manager. The temporary manager demonstrated a good awareness of residents needs and there was evidence that she had started to address some of the many shortfalls in the home. The service manager stated that recruitment to the manager posts was taking place and that they hope to put someone forward for registration with CSCI in June 2005. The home had a number of Policies and Procedures in place for the management of Health and Safety. Some of these were examined. A fire drill Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 22 was overdue and Fire safety training for staff was required. Manual Handling risk assessments required some further development. Risk assessments pertinent to residents must be implemented in all relevant areas; those that had been implemented must be kept under review. The staffing levels and evidence that staff are suitably trained was of concern and required attention as highlighted in other sections of the report. The management of the home have a duty to ensure that all staff are aware of their responsibilities when working at the home. There was particular concern regarding staff locating the whereabouts of risk assessments. This raises questions about staff and management’s awareness of risk assessments and how these are referred to on a daily basis. Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 1 1 x x 1 Standard No 11 12 13 14 15 16 17 1 2 1 x x 3 x Standard No 31 32 33 34 35 36 Score x x 1 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holland Street (76) Score 1 1 x x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 1 x E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (1) (2) Requirement All residents must have a care plan that includes all aspects of personal and social support. The care plan must be kept under review and involve the resident, their family,friends and advocate. (Previous timescale 1/4/05) Behaviour guidelines must be kept under review. Daily records must include residents response to care and when choices have been made and record when decisions have been made by others and why. (Previous timescale 1/4/05). Risk assessments required significant development.They must be implemented in all relevent areas.They must be kept under review.(Previous timescale 1/4/05) The home must evidence how residents independent living skills are met. Residents must be offered a choice of activities.The range and choice of activites must be kept under review . The home must be able to evidence how they support Timescale for action 31/8/05 2. 3. YA6 YA7 12 (1) (a,b) 15 (1) 31/7/05 30/6/05 4. YA9 13 (4) (a,b c) 31/8/05 5. 6. YA11 YA12 12 (1) (a)15 (1) 16 (2) (m) 12 (1) (b) 31/8/05 31/8/05 7. YA13 31/8/05 Page 25 Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 8. YA17 16 (2) (h) 9. 10. 11. 12. YA19 YA19 YA18 YA18 12 (1) (a) 12 (1) (a) 13 (5) 23 (n) 13. 14. YA22 YA23 22(8) 13 (6) 15. 16. 17. 18. 19. 20. 21. YA24 YA24 YA24 YA24 YA24 YA24 YA24 23 (2) (d) 23 (2) (d) 23 (2) (d) 13 (4) (a) 23 (2) (d) 23 (2) (j) 23 (2) (d) residents to become part of and participate in the local community in accordance with their assessed needs and care plan.(Previous timescale 1/4/05). The home must evidence how they support residents to plan,prepare and serve meals. Any facilities provided must be kept clean and safe. The home must improve the loggng ,moinitoring and follow up of health care matters. Health Action plan must be introduced for all residents. Manual Handling risk assessments must be kept under review. A Occupational Therapy assessment of the bathrooms was required. CSCI must be informed of the outcome. The homes complaint log must include details of follow up and outcomes. Minor development of the Adult Protection Procedure was required.(Previous timescale 1/4/05). Broken tiles in bathroom A must be repaired and pipe work boxed in. Ceiling panals in bathroom A must be repaired. The shower curtain in bathroom A had mould on and required replacement. The water temperatures required testing and regulating A wing. The tiles in bathroom B required resealing around the bath. The bath on C wing required resealing around the bath. The ceiling on C wing was damp and peeling and required repainting. 30/6/05 30/6/05 30/9/05 30/6/05 31/7/05 30/6/05 31/7/05 30/6/05 30/6/05 14/5/05 8/5/05 30/6/05 30/6/05 30/6/05 Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 26 22. 23. 24. 25. 26. 27. 28. 29. 30. YA27 YA24 YA24 YA24 YA24 YA24 YA25 YA24 YA24 31. 32. 33. YA24 YA27 YA24 23 (2) (c ) The shower room on D wing required repairing. 23 (2) (d) Touching up of paintwork was required throughout the home. 23 (2) (p) Light fittings throughout the home required auditing any not working must be repaired. 23 (2) (c ) Exractor fans throughout te home required cleaning. 23 (2) (d) The kithchen on C wing required cleaning, including the cupbords shelves and fridge. 23 2)( b) The damp on the wall in the hallway required attention and the paper repaired. 23 (2) (n) The layout of bedroom for resident with additional physical needs required review. 13 (4) (a) The home must review the use of electrical sockets and the use of extension leads 16 (2) (c ) All bedrooms must be audited against the National Minimum Standards For Younger Adults.Any shortfall must be provided. (Previous timescale 1/4/05). 23 (2) (d) Carpets required cleaning. 23 (2) (c ) The specialist bath on A wing (j) (n) required repair. 23 (2) (b) A programme for planned maintenance and renewal which is a condition of registration was required. (Previous timescale September 2004). 23 (1) (a) Plans must be agreed with CSCI 2 (a) with stated timescales for the future reprovision of this service to ensure commensurate with fitness for purpose for the needs of the client group.(Previous timescale September 2004). 18 (1) (a) Vacant posts must be appointed to. Minimum staffing levels must be maintained. The home must provide bi monthly updates to CSCI.(Previous timescale E54 S33648 Holland Street V225614 060505 Stage 4.doc 10/6/05 30/6/05 30/6/05 10/6/05 12/5/05 30/6/05 30/6/05 30/6/05 30/6/05 30/6/05 10/6/05 31/7/05 34. YA24 31/7/05 35. YA33 6/7/05 Holland Street (76) Version 1.30 Page 27 16/3/05) 36. 37. YA33 YA34 A risk assessment on staffing levels was required. 7,9,19 Each staff member employed in Schedule the home must have the 2 following information.Recent photograph,evidence of qualifications,two written references,eveidence of medical fitness,application form,CRB check. Staff induction programmes must be completed.(Previous timescale 1/4/05). 18 (1) (c ) Staff training records required updating. A training needs assessment must be carried out on the staff team. 18 (2) Staff must receive regular recorded supervisions at least six a year with records kept. (Previous timescale 1/4/05). 8 (1) (a) A permament manager must be (b) (i) appointed. 23 (4) (e) A fire drill was required. 23 (4) (d) Fire safety training for staff was required. 18 (1) (a) 31/5/05 31/7/05 38. YA35 31/7/05 39. YA36 31/7/05 40. 41. 42. 43. YA37 YA42 YA42 31/8/05 31/5/05 30/6/05 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 Good Practice Recommendations Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holland Street (76) E54 S33648 Holland Street V225614 060505 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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