Inspection on 31/01/06 for 228 Kingsbury Road

This inspection was carried out on 31st January 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 29 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

228 Kingsbury Road 06/02/07

228 Kingsbury Road 25/05/06

228 Kingsbury Road 20/09/05

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 Kingsbury Road, 228 Erdington Birmingham B24 8QY Lead Inspector Alison Ridge Unannounced Inspection 31st January 2006 12:30 Kingsbury Road, 228 DS0000065003.V281505.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 Kingsbury Road, 228 DS0000065003.V281505.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. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kingsbury Road, 228 Address Erdington Birmingham B24 8QY 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 382 5493 Caretech Community Services Limited Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: 228 Kingsbury Road is an adapted domestic property. The home offers accommodation over three floors, and comprises of a lounge, relaxation room, kitchen/diner, ground floor wc. On the first floor are three single bedrooms, and a bathroom. On the second floor is a staff sleep in room/office. The home has a rear garden, and a laundry is located in out buildings. Service users require full mobility to live in this home. The service provides care and support to three adults who have a learning disability, and some behaviour that challenges. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this visit over the afternoon of one day. The visit was unannounced. During the visit information was collected by talking with the people who live in the home and observing the care and support they received. The inspector spoke with the deputy manager and a carer who had started work in the home approximately three months ago. A tour of the shared areas of the home was undertaken. The inspector looked at records about care, health and safety and money. It is suggested that this report be read alongside the report of the last inspection of this home, to give a fuller picture of what life is like in this home. The inspector extends her thanks to every one who assisted with this visit. What the service does well: What has improved since the last inspection? The range and quality of food available was improved. There was a wide range of fresh products. The staff had bought fresh milk, fruit, vegetables, and the menu showed a lot of food was freshly prepared and not processed. The cleanliness of the home had improved. It was evident all rooms inspected had been cleaned and vacuumed. The record of activities being undertaken had improved. It was good to see that people are regularly getting to college and going out sometimes for leisure. This is an area that has improved but which needs to keep getting better. The way staff supported service users had improved. There was a much greater emphasis on people undertaking tasks for themselves with support. It was really positive to see people being supported in the kitchen to make drinks, lunch or get a snack. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 6 Staff had started to develop some new records about care. These were individual to each person, and recorded the preferences of each person. Some of these gave you a good idea of the care and support the person required. Caretech has provided all staff with a lot of training. This area wasn’t fully assessed, but it was reported that all staff have been provided with mandatory training, and some training about the specific needs of the people who live at 228 Kingsbury Road. What they could do better: Fourteen of the twenty-seven previously made requirements have been carried forward. A further two have only been partly met. Work to address these shortfalls must be undertaken. The premises require improving throughout to provide accommodation at an acceptable level that ensures the safety and comfort of people living and working in the home. All the areas inspected from the front door, through the home, including the lounge furniture, soft furnishings, kitchen, bathrooms, flooring, windows and heating required attention. Some repairs that had been made, as requirements in the last report had not been mended. Records showed the boiler had broken down over the Christmas and new-year period. This resulted in the heating not being available. At some points over this period the shower was also broken, meaning no hot water was available for washing. Records of work tickets showed this is problem keeps repeating and an immediate requirement was made that this be sorted out properly. There are staff vacancies. The number of staff employed wasn’t enough to cover the rota and temporary staffing were being utilised. The provider needs to recruit to these vacancies, and ensure at some points over the week and weekend adequate staffing is provided for people to go out. Records showed that one service user had hurt other people living in the home and themselves. The plan in place, and the way staff were observed to, and had recorded what they had done in these instances was not good enough. It was made an immediate requirement that this be further addressed and the right people notified of when an incident occurred. The staff were observed to be supportive and kind to the people living in the home. It wasn’t evident that they had the required level of skill or awareness about sensory impairment, or challenging behaviour to be able to support the service users as best as possible. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 7 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. Kingsbury Road, 228 DS0000065003.V281505.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 Kingsbury Road, 228 DS0000065003.V281505.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): X Not assessed at this inspection. EVIDENCE: This home has a stable service user group. There are no residential vacancies and there have been no new admissions to the home. These standards were not assessed. Kingsbury Road, 228 DS0000065003.V281505.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, 8, 9, 10 Service users needs and risks are not well planned for and specialist needs are not well met. Service users are encouraged to participate in the running of the home, and consulting with service users about life in the home has improved. All information about service users is securely stored. EVIDENCE: The plan of one service user was assessed. Some work had been commenced on the development of plans since the last inspection, this was positive, but it was evident that the staff required support to develop the plan to the required level. The plan identified the service users needs, but did not go on to explain how they were to be met. Examples of this included, ”I need staff to help me in the community” and “I need support to slow down when eating”. These plans need further detail to make explicit the support needs the person has and how they are to be met. It was positive that some goal setting had occurred for the service user, but it was not possible to establish who had set the goal, why, who was going to support the service user to meet it, or how the goal was to be worked towards. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 11 There was also no record of if the goal had been achieved or if it was something the service user benefited from or enjoyed. The staff plan to commence “talk time” with the service users. This will be a way of consulting people on the running of the home. The risk associated with the one service tracked had not been well planned for. It was evident that work to address this was underway. At the time of inspection two risk assessments were available. One was regarding using sparkler fireworks and the other was blank. This was of concern as the risks faced by and presented by this service user are significantly greater than this. Some draft documents were later sent to the CSCI regarding risks associated with this person. These need to be completed and to become part of the plan of care for this service user. All the information stored in the home was secure. The staff interactions with service users were friendly and positive. No breaches of confidential information were noted. Kingsbury Road, 228 DS0000065003.V281505.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): 11, 12, 13, 14, 15, 17 The opportunities for people to undertake development and leisure both in the community and at home have increased. The frequency with which community access is occurring continues to require improvement. Service users are supported to stay in touch with their family and with people who are important to them. The range of food available and offered was good. Plenty of fresh foods had been provided, and service users had a choice about what to eat. EVIDENCE: The opportunities presented to one of the service users for the month of January were assessed. It was positive to see that the planned opportunities to attend college had been attended. The opportunities to undertake community activities including the Gateway club, visiting the pub, accessing public transport and local walks had increased. The inspector noted that all three weekends tracked were spent at home, with no opportunity to access the community. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 13 The opportunity to undertake activities at both evenings and weekends is still an area that needs to improve. It was positive that some activities of specific interest to the individual had been identified. It would be positive if these as well as group activities continue to develop. It was positive to see how service users were encouraged to participate in the home, with cleaning, laundry and cooking. The level of support or programme identified for the service user to develop these skills can then be utilised consistently by all staff, and would enable evaluation to be undertaken, and progress or effectiveness measured. It is recommended that staff look at the purpose of activities, to ensure people have a mixture of development, leisure and exercise and include this in the service users plan. It was positive to hear from service users, and to read in daily records that contact with family and friends is maintained and encouraged. The planned menu was nutritious and varied. It included a range of foods, and takeaway meals. The food offered and observed during the inspection was of good quality. Kingsbury Road, 228 DS0000065003.V281505.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 Service users are supported to undertake personal care to a high standard. The plans regarding the support required to undertake this required further development. Service users routine healthcare needs were generally being well met. Specific needs in the areas of challenging behaviour, and sensory impairment were not well met, or planned for. EVIDENCE: The inspector was pleased to meet all three service users, and they all appeared well dressed, and to have been supported with personal care. It was evident service users had been supported to style their hair, and shave as required. One service users plan of care gave some individual guidance on meeting personal care needs. The plan needed further work to cross reference to other relevant documents, and to make clear how the care was to be delivered. The staff had commenced work on completing a health assessment. This was largely blank, but potentially useful when complete. It was evident weight monitoring had been undertaken routinely. The service user tracked had additional support needs in the area of difficult to manage behaviour and sensory impairment. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 15 It was not evident that either of these needs were being well met, or that the plans available were robust in these areas. Staff had not undertaken routine evaluation of the incidents to inform or direct care practice. In one incident tracked a known behaviour trigger was poorly managed, which resulted in the harm of another service user. The reactive management strategy made reference to the service users weight gain, but no further plan regards healthy eating or addressing this was in place. The inspector observed a staff support one service user with lunch preparation. The interactions were all well meaning, but overloaded the service user with information. It was not evident that staff had awareness of this, and it is required training consistent with the needs of the service user be delivered to all staff. Kingsbury Road, 228 DS0000065003.V281505.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 The policy to underpin investigation of service users and stakeholders concerns is robust. The adult protection policy does not direct staff to ensure service user safety, and to contact social care and health, which could result in a service user being harmed or an investigation being compromised. EVIDENCE: The home has received no complaints. The policy regarding complaints was assessed and found to be robust. It was positive to hear that a more accessible policy is in draft for service users. The Adult Protection policy did not make clear that the reader’s primary responsibility was to make the service user safe, and to contact social care and health. The policy made no reference to the local multi-agency guidelines. It has been required that this be reviewed in light of these observations. During the inspection incident records that recorded incidents of service user to service user abuse were noted. These incidents had not been reported to either social care and health as is required under Adult Protection guidelines or to the CSCI under regulation 37. Of further concern was that no clear strategy or guidelines were in place to underpin behaviour leading to such incidents, and that they had not been developed in the interim period since the incident. An immediate requirement was made regarding this incident. Kingsbury Road, 228 DS0000065003.V281505.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, 25, 27, 28, 29, 30 228 Kingsbury Road is domestic in size and style, and has a very homely feel about it. The premises require urgent attention in the near future to provide an acceptable level of accommodation and comfort. EVIDENCE: The inspector noted that from the front door, through the home to include the décor, flooring, comfortable lounge furniture, kitchen, toilets and bathrooms, soft furnishings, and bedrooms improvement was required. The dining room table required emergency repair at the time of inspection, as one leg dropped out. The inspector is aware of the provider’s intention to address this, but timescales originally stated in which this work would be addressed have now passed, and it has been required a new schedule of work be provided. It was of concern to note that repairs identified as being required at the last inspection remained unchanged. Of greatest concern was the internal glass of the oven door, which isn’t attached to the oven, and is at risk of falling out. Of serious concern was problems observed and reported regarding the provision of heating and hot water. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 18 Water temperature records reported the boiler was broken between January 1st and 12th 2006. The same record showed the shower to be out of operation on December 29th 2005 and to remain out of order on January 13th 2006. Staff on duty could not confirm that adequate heating or hot water was available over this period. An immediate requirement was made regarding this, and the inspector has since been advised a new boiler will be provided this month. The service users have no special needs regarding aids and equipment for mobility, but it is required that adaptations for people with impaired vision be explored for one service user. He was observed to require support with the location of food and utensils on the table at meal times and in some instances in negotiating level changes around the home. It was not evident that any special consideration had been made re providing adaptations to address this. The home had been recently cleaned in all of the areas inspected. The standard of cleanliness of furniture, the bathrooms remained of concern, as these fittings are now deeply soiled and require replacement. An offensive odour was evident in the ground floor wc and first floor bathroom. Kingsbury Road, 228 DS0000065003.V281505.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): 33, 34, 35, 36 Staff show commitment, and are supportive and kind in interactions with service users. Recruitment of staff is required to ensure adequate numbers of staff, and that service users are supported by people they know, and who know their needs. Staff are checked prior to starting work in the home. A high level of training and induction is provided. Supervisions need to planned and undertaken to ensure staff feel competent and supported with their job role. EVIDENCE: The rota showed two staff are provided for the times when three service users are at home. This on some occasions increases to three with support from an agency staff member. It is required that the additional management support hours be shown on the rota, that the agency staff allocated be named on the rota and that the start and end of times of shifts be made clear. The rota identified 46.5 hours of agency staffing was to be provided in the week following inspection. It is required that these posts be recruited to. The staff recruitment, training and supervision files were not available to the staff on duty. It was required that the providers representative review three staff files in the next providers regulation 26 visit. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 20 Information was received regarding two staff. The information provided confirmed that recruitment checks had been undertaken, and that staff had received induction into the home. The most recent staff starter had been provided with comprehensive training in all mandatory areas, and in epilepsy, autism and physical intervention. For both the staff records sampled it was evident supervision was required. Kingsbury Road, 228 DS0000065003.V281505.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, 41, 42 The-day-to-day running of this home ensures service users basic needs are met. The absence of skilled and clear management results in service users specific needs being poorly met. Testing of appliances ensures the safety and welfare of service users, staff and visitors. This needs to be further addressed with the development of all required risk assessments, and with effective reporting and recording of incidents and accidents. EVIDENCE: This home is without a registered manager. The deputy manager is covering this vacancy with part time support from another registered manager within the organisation, and the service manager from Caretech. It was evident that the staff are motivated to move forward, but that strong and focussed leadership is required to facilitate this. It was pleasing to hear that manager has been recruited, subject to preemployment checks. It is required application for registration be made with the CSCI as soon as is possible. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 22 There was on display a copy of the homes registration certificate and employers liability insurance. Monthly provider visits are undertaken, and forwarded to the CSCI. These visits are undertaken to a high standard, and show a detailed visit is made to the home each month. Service users finances all tallied with the records available. Receipts were provided to underpin purchases. It was evident that benefits were being received. Incidents that should have been reported to the CSCI under regulation 37 were noted in the home. It is required that staff be made aware of the remit of reporting and that these be forwarded for any future events. The staff had undertaken testing of the fire alarm as is required. Servicing and maintenance of gas, electric and fire equipment had been undertaken as required. Risk assessments for food, fire, premises and staff were requested. It has been required that the terms high, medium and low risk be defined, that the date the assessments were implemented and reviewed be stated and that staff complete a read and sign. The assessments were all generic and the specific risks associated with this service user group, staff group and premises had not been explored. It is required these issues be addressed. Risks to staff to include lone working, and the provision of gender sensitive care had not been assessed. Kingsbury Road, 228 DS0000065003.V281505.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 X 2 X 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 3 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 1 28 1 29 1 30 2 STAFFING Standard No Score 31 X 32 X 33 1 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X 3 1 3 LIFESTYLES Standard No Score 11 2 12 2 13 1 14 1 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 X X 1 X X X 2 2 X Kingsbury Road, 228 DS0000065003.V281505.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 YA6 Regulation 12 15 Requirement Timescale for action 01/06/06 2. YA6 3. YA6 4. YA8 5. YA9 6. YA9 Not met from the previous inspection. Plans that fully underpin the needs of service users must be developed. 12(2)(3) Not met from the previous inspection. Service users must be consulted regarding the development and review of their plan. 12(3) Goal setting for service users must clearly show: who had set the goals, how they were agreed upon, who is responsible for meeting them, how it will be identified if they are met, when the goal was set, or who the goal is intended for? 12(2)(3) Not assessed at this inspection. 16(2)(m-n) Matters identified in service users meetings must be explored, and evidence of action taken made available. 13(4)(a-c) Risks posed by and undertaken by service users must be assessed, and control measures implemented. 13(4)(a-c) Not met from the previous inspection. An effective tool for assessing DS0000065003.V281505.R01.S.doc 01/06/06 01/03/06 01/03/06 17/03/06 17/03/06 Kingsbury Road, 228 Version 5.1 Page 25 7. YA9 8. YA11 9. YA14 10. YA18 11. YA19 12. YA19 13. 14. 15. YA19YA33 YA20 YA23 risk must be developed and implemented. 13(4)(a-c) Not met from the previous inspection. Risk assessments must be developed to enable service users development. 12(1)(b) Not met from the previous inspection. Opportunities for service users growth and personal development must be included in their individual plan. 16(2)(m-n) Partly met since the last inspection. 12(1)(b) Access to community activities must be increased. Service users must have access to a range of community activities of their choice. 12(1)(a-b) Not met from the previous 15 inspection. Care documents must provide staff with specific information on how to meet service users personal care needs. 12(1)(a) Not met from the previous 13(1)(b) inspection Care documents must provide clear guidance on how all health care needs are to be met. 13(4 a-c) Partly met since the last 13(6) inspection. Difficult to manage behaviour must be risk assessed and planned making reference to DOH guidance on physical interventions. . 18(1 a,c,i) Staff must be provided with training to enable them to meet service users needs. 13(2) Not assessed at this inspection. The medication store must be kept clean and in good order. 13(6) The adult protection policy must be reviewed and developed to ensure staff are instructed to make the service user safe, and DS0000065003.V281505.R01.S.doc 01/05/06 01/05/06 17/03/06 01/04/06 01/04/06 01/04/06 01/06/06 01/03/06 01/05/06 Kingsbury Road, 228 Version 5.1 Page 26 16. YA23 13(6) 17. YA24 23(2)(b) 18. YA24 23(2)(b) 19. YA24 23(2)(b) 23(5) 20. 21. YA24YA27 YA29 23(2)(j,p) 23(2)(n) 22. YA30 23(2)(d,p) 23. YA33 18(1)(a) to contact social care and health. The policy must make reference to local multi-agency guidance. All incidents of service user to service user abuse must be reported under adult protection procedures. Not met from the previous inspection. Décor and furniture throughout the home must be updated and replaced where broken and worn. (This includes the bathroom, toilet, kitchen, soft furnishings, lounge furniture, front door and windows.) Not met from the previous inspection. Repairs including securing the oven door glass and repairing plaster in the back bedroom must be undertaken. Not met from the previous inspection. The kitchen must be redecorated, to include the replacement of the floor. A consistent and reliable supply of heat and hot water must be available at all times. The provision of adaptations to support people with sight impairment must be explored and obtained if required. Not met from the previous inspection. Odour management must be improved in the first floor bathroom. Not met from the previous inspection. The number of staff provided must be adequate to enable service users to undertake activities of their choice, consistent with their peers. DS0000065003.V281505.R01.S.doc 20/02/06 01/06/06 20/02/06 01/06/06 20/02/06 01/05/06 01/06/06 01/04/06 Kingsbury Road, 228 Version 5.1 Page 27 24. 25. YA36 YA37 18(2) 8 9 37 13(4 b-c) 26. 27. YA41 YA42 All staff must receive formal recorded supervisions. A suitably qualified and experienced manager must be recruited and make application to the CSCI for registration. The CSCI must be informed of all reportable incidents under regulation 37. Risk assessments for fire, food, staff and the premises must be developed. These must be specific to the risks associated with this home, service user and staff group. 01/04/06 01/05/06 20/02/06 01/03/06 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 YA41 Good Practice Recommendations It is recommended that the arrangement of service users files be reviewed and that information be stored and presented in an easy to access and understand manner. Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 28 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 Kingsbury Road, 228 DS0000065003.V281505.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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