Inspection on 06/02/07 for 228 Kingsbury Road

This inspection was carried out on 6th February 2007.

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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

228 Kingsbury Road 25/05/06

228 Kingsbury Road 31/01/06

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 Donna Ahern Key Unannounced Inspection 6 and 7th February 2007 17:00 th Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 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.V317388.R01.S.doc Version 5.2 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.V317388.R01.S.doc Version 5.2 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 Nicola Ward (waiting registration with CSCI) Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2006 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. The fee level for the home is per £1301.92 per week Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit was unannounced involved one inspector and took place over an evening and a day lasting nine hours. This was the homes second key inspection for the inspection year 2006-2007. During the fieldwork the inspector met all service users, observed the opportunities and support provided to service users, looked at the premises, and read records about care, staffing, and health and safety. Service users have complex needs and have limited verbal communication therefore their comments are not included in the report. Information about service users quality of life is based on observations and information gained from reading records. The home is required to report incidents, accidents and other events that occur in the home to CSCI. These are called regulation 37 notifications. All information reported via a regulation 37 notifications since the last inspection was analysed prior to the fieldwork visit. A pre inspection questionnaire was completed by the manager and returned to CSCI. Information from the questionnaire was used to help complete this report. What the service does well: What has improved since the last inspection? A lot of progress had been made on previous requirements which indicates that the manager and staff have worked hard to put things right and make it a nicer home for people to live in and providing a better quality of life for service users. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 6 Care plans have been improved so that staff have the information they need to enable them to meet service users needs. Systems are in place for the monitoring of activities including service users response to activities so that this information can inform future planning. Service users are supported to attend health care appointments so that there health care needs are met. When an incident has occurred in the Home the manager has taken appropriate action to protect service users and inform relevant people such as Adult and Communities (Social Services). Lot of work has been done to the Home to make it a clean, fresh, comfortable Home for people to live in. Service users bedrooms have been painted and new furniture provided. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have information to enable them to make an informed choice whether to live in the home. EVIDENCE: The Home has a stable service user group there have been no new admissions to the Home for a few years. Social Care and Health assessments were seen in service user files. The Admission procedure states that a full assessment would be undertaken prior to admission and a three-month settling in period would take place to enable the service user to decide if the home meets their needs. The contracts that explain the terms and conditions to service user had been revised and were in the process of being signed by service users and their representatives. The contract had details of fees charged, details of additional charges and arrangements for terminating the contract. The statement of purpose was looked at and describes the services and facilities provided. The service user guide must be developed so that it is specific to Kingsbury Road. The provider should explore how information could Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 9 be made available in different formats suitable for the people who live or may choose to live at Kingsbury Road. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further development of service users care plans is required so that staff have the information they need to enable them to meet service users assessed needs and goals. Risk assessments must be further developed so that sufficient arrangements are in place to ensure the risks service users face are well managed. EVIDENCE: The previous inspection report raised concern about service user individual care plans. They were assessed as not reflecting service user needs and did not provide staff with guidance on how they should meet service user needs. It was positive that progress had been made on implementing a new care plan format and for the purpose of this inspection two peoples care plans were Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 11 looked at. Care plans include information about people’s personal care needs, communication, independence, likes and dislikes, daytime occupation, cultural needs, relationships and emotional needs. A separate folder referred to as “all about me” had each persons support plan and a pen picture of needs and provides staff with the information they need on a day to day basis to support service users and meet their needs. There was evidence that the care plans had been discussed with the service users and signed. Some further development of these is required so that individual goals and aspirations are identified and worked towards. Person centred plans are in the process of being implemented. These are care plans that start with the person, not the service and take into account the individuals wishes about what they want to do and includes their requests on lots of things such as leisure, education and housing. They are produced in a format suitable for the individual such as easy read and picture format and will be a really good development for the service users at Kingsbury Road. Behaviour guidelines, reactive management plans and guidelines regarding self-injurious behaviour were on peoples file and ensure that staff have the information to support service users appropriately, consistently and safely. The service user had signed the guidelines, which indicates their involvement. However, the guidelines and behaviour plans had not been dated when implemented and the review of such plans requires a full evaluation to be done and should include reference to relevant incidents to ensure the plans are still appropriate. A number of risk assessments were in place for both service users who files were looked at and include use of public transport, swimming and epilepsy. Some of the risk assessments were detailed and specific to the individual and what support they need to minimise risks. However, some risk assessments required some additional information such as the bathing risk assessment which must be specific about the support the person requires and the level of supervision they require from staff. The swimming risk assessment required review to reflect current practice of only one staff supporting this activity. Some of the risk assessments were generic including “using the community” and “use of the kitchen” these must be specific to the individual so that individual service users can be supported to develop their independence within a risk assessment framework. Progress had been made on developing assistance with people’s communication so that they can make decisions about their own lives. Staff interacted well with service users during the fieldwork visit. Advice had been sought from speech and language therapy and a photograph and picture communication folder had been implemented for a service user. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s):12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported to maintain contact with people important to them so they maintain personal relationships. Service users have opportunities to take part in a variety of activities but staffing levels must be reviewed so that individual needs and preferences are met. EVIDENCE: Service users all have the opportunity for personal development at day placements including day centres and local colleges. Records seen and discussions with service users and staff indicated that service users are also supported to access facilities in the local community including shops, meals out, walks and swimming. It is positive that monitoring of activities is taking Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 13 place and service users response to activities is recorded so that these can help inform future planning. Staffing levels at times do restrict opportunities for service users to go out. This is referred to in more detail under staffing standards of the report. It is advised that the arrangements for funding activities is made clear as sometimes service users fund these themselves and sometimes it is funded through the organisation. A people carrier is shared between two other Homes owned by the organisation in the local area. Service users are also encouraged to walk, use public transport and ring and ride. Service users will be making a contribution from their mobility allowance towards the cost of the vehicle this will need to be clearly documented and agreed with service users and their representatives. Two service users went on holiday in October 2006 to Great Yarmouth and one service user stayed at Home and was supported to go out each day. Observations during the fieldwork were positive service users were prompted and supported to take part in household tasks including clearing and wiping the tables after meals and taking out the rubbish. Interactions between service users and staff were friendly and relaxed. Service users freely accessed all areas of the Home and showed the inspector around. Service users are well supported to maintain contact with relatives and friends. Some of the service users have regular visits to stay with their family. Service users received appropriate support with their meals. A service user with visual impairment has a place mat and is supported to eat independently. Menus seen indicated that a range of nutritious and culturally appropriate food is provided. It was advised that menus are monitored to ensure that the recommended five fruits and vegetables a day are available so that all service users are offered a healthy diet. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s):18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user personal care needs are well met. Service users were well presented in a style that reflected their gender, culture and preferences. Medication is well managed ensuring that service users receive their medication as prescribed. EVIDENCE: Service user individual plans had details of people’s personal care routines and preferences. None of the current service users require assistance with moving and handling. The home is not suitable for a person with restricted mobility there are no adapted facilities and no mobility aids. The manager had consulted with RNIB regarding equipment for a service user who has a visual impairment it was advised that the person is supported to be as independent as possible within their own environment. The person was very well supported and enabled to carry out task and household jobs and to move freely around the Home. Some Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 15 aids have been purchased following the advice from RNIB including a talking watch, a place mat and an indictor for making hot drinks. Service users were appropriately dressed in accordance to their age and culture. Health care notes looked at indicate that service users are supported to attend routine G.P, dentist, and optician appointments so their health care needs are met. Health Action plans have been implemented. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. The recordings of outcomes of appointments were generally satisfactory so that health needs and any follow up action required could be monitored and actioned. Some parts of the Health Action Plan need completing so that it is fully implemented. The monitoring of peoples weight is important for the early detection of other health problems or complications. Service users weight monitoring recordings indicate that checks are done monthly. Staff doing a sleep in shift supports Service users during the night. Risk assessments must be completed on service users needs during the night and how they would seek assistance if required, these must underpin any staff guidelines and form part of the persons care plan. Service users require support from staff to take their medication. It was positive that service users medication had been reviewed with their G.P. The medication administration records (MAR) cross-referenced with the blister packs indicating medication had been given as prescribed. Written protocols are in place to describe the circumstances which medicines given on an as required basis (PRN) should be given. It was recommended that medication records are developed to include a photograph of each service user and details how the person likes to take their medication. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Caretech has a robust complaint procedure and vulnerable persons policy ensuring concerns about the service can be raised and addressed and that service users would be protected if the policies were followed. EVIDENCE: The complaints policy was assessed at the previous inspection as robust and if followed would ensure concerns are dealt with thoroughly. There have been no complaints since the previous inspection and CSCI have received no complaints about the Home. It is recommended that the complaints procedure is produced in a format more accessible for service users. The people who live at Kingsbury Road have complex needs and at times present behaviour that can be challenging. Behaviour management plans are in place and these required some minor attention as raised under “Individual needs and choices” section of the report. Incidents have occurred in the Home, which have required referring to Social Care and Health under Adult Protection Procedures. CSCI have also been informed and documentation seen indicated that appropriate action has been taken by the manager to protect service users from harm and inform relevant professionals of any concerns. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 17 There are systems in place for the reporting and recording of accidents and a monthly summary report is completed. The manager said the purpose of this is so that accidents are monitored and repeated accidents are noted and any actions to reduce them are implemented. It was noted that there are still some incidents of where the cause of minor injuries to service users is unknown. Further exploration to the possible cause of these injuries should take place and possible strategies for prevention should be considered to ensure service users safety. It was advised that a log of regulation 37 incidents is kept in the home to assist with an audit trail of information and provide a more accurate system for auditing incidents. All service users require assistance to manage their finances. The home has a system for the recording and auditing of money received in and spent by individuals, so that service users finances are protected. Two peoples money was checked and amounts held balanced with the records seen. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s):24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and comfortable home that meets their needs. EVIDENCE: Considerable improvements have been made to the physical standards of the Home since the last inspection making Kingsbury Road a comfortable and welcoming place to live. Service users showed the inspector their bedrooms; all service users have had new beds one of the service users picked a new double bed. The bedrooms have been redecorated and service users have picked new furniture including wardrobes and cupboards, some of the new items were on order waiting on a delivery date. Service users seemed really pleased with their bedrooms. The lounge has had a new carpet fitted; new pictures rugs and throws have been purchased to make this a welcoming and comfortable room. The kitchen Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 19 has been painted and new flooring fitted and a new freezer and dining table provided. The bathroom has been refurbished some work remains outstanding to this room before the finishing touches can be fitted including blinds for the window and hand drying facilities secured to the wall. The manager said that this was all in hand and should be completed shortly. All areas of the Home were clean and the arrangements for food storage and handling were adequate ensuring service users are not put at risk. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels must be reviewed so that adequate staff is available to meet the social and recreational needs of the people living at the Home. Staff receive the training to enable them to meet service users assessed needs. EVIDENCE: Staffing levels consist of two staff on duty across the day and one staff member sleeping in on call at night. There have been some staffing difficulties over recent months however a deputy manager was recruited in December 2006 and the manager said that there should be a full compliment of staff in place by the end of February 2007. The staffing compliment currently consists of only five staff members. Service users have complex needs and require one to one staff to support them within the community to successfully and safely engage in suitable Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 21 activities. Sometime due to service users needs higher levels of staffing is required. Current staffing levels restrict opportunities for service users to engage in some activities especially in the evening or at weekends. staff are also responsible for all cooking and cleaning tasks. As raised under the core standards “Lifestyle” staffing levels must be formally reviewed to ensure that adequate staff are available to meet service users assessed needs. Currently all staff are female the manager said that this was due to who had applied for positions within the Home. She would welcome male staff applying for positions to compliment the staff team and so that the male service user would have staff of their gender available for personal support. From observations during the fieldwork the inspector concluded that service user were very comfortable and relaxed with the staff on duty throughout the fieldwork visit. The recruitment records for two staff were sampled. Checks of the person’s suitability to work in the home had been made; including satisfactory Criminal Records Bureau checks, completed application form, references and proof of identification ensuring robust recruitment procedures are in place to safeguard service users. Training recently completed and scheduled for the next few months include both mandatory and those reflective of service users needs including Non Violent Crisis Intervention, First aid, Team building, Empowering service users, Autism, Manual handling and Medication training. This should ensure that staff have the skills and knowledge to support service users. Staff meetings take place about once a month. Agenda and Minutes were available for staff to read and indicated that service user issues and care practice issues are raised and discussed and provide a good forum to enhance communication within the Home and develop good standards of care practice. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some development of Heath and Safety systems is required so that service users live in a safe Home. EVIDENCE: The manager has been in post for ten months but has not yet made an application to be registered with CSCI. She has a number of years experience with the client group and was previously a registered manager. Throughout the inspection the manager was open and welcoming to the inspection process. The relationships between the manager, service users and staff were good. Good progress had been made on previous requirements indicating compliance with the regulations. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 23 The manager does three shifts per week hands on and is allocated sixteen management hours per week. In light of the complexity of the needs of service users and the responsibilities required of a registered manager it is advised that this is reviewed and the amount of management hours increased. The service manager undertakes monthly regulation 26 visits to monitor that the home is being managed appropriately. Copies of the report are available in the home and sent to CSCI. The reports indicate that a thorough visit takes place. Copies of previous CSCI reports were available. The manager said the outcomes of inspections are shared with service users where possible and the staff team. A quality audit system is in place and the Home had a full unannounced audit in 2006. An action plan was drawn up of the recommendations and requirements. The manager said she was in the process of devising a questionnaire that will be sent to service users, their relatives and other stakeholders so that their views are sought to measure the success of the Home in meetings its stated aims and objectives. A number of health and safety records were looked at. The manager had also completed the pre inspection questionnaire to confirm dates of health and safety checks. Fire safety records showed that the fire alarm system is tested and serviced as required so that it is kept in a safe working condition. Fire drills were being carried out every six months so that service users and staff have the opportunity to practice safe evacuation in the event of an emergency. It was advised that details of staff names are recorded when the drills take place so that the manager can ensure all staff get this training. Details of any issues raised when the drill took place should also be documented. The Fire risk assessment was reviewed in November 2006. A minor addition was required to a service users fire risk assessment so it had details about the person’s visual impairment. General risk assessments for the environment were due for review some of the assessments were generic and must be developed so they are specific to Kingsbury Road. Water temperature checks are completed monthly to prevent the risk of scalding. The records need to show what action staff have taken to safe guard service users when recordings above the required temperature of 43 degrees are noted. Certificates of Gas and Electrical tests were available and indicate that the building is maintained for the protection of service users. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 24 A tour of the premises at the time of the fieldwork found no obvious health and safety hazards that would place service users at risk of harm. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 25 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 3 X X 2 3 Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 5 (1) Requirement The Service user Guide must be developed so that it reflects the service at 228 Kingsbury Road. Further development of peoples care plans is required so that goals and aspirations are identified and monitored. Behaviour guidelines must be dated when implemented and kept under review. Risks posed by and undertaken by service users must be assessed, and control measures implemented. Risk assessments must be completed for service users needs during the night. The cause of unknown injuries to service users require some further exploration to ensure their safety. Not met from the previous two inspections. Timescale for action 31/03/07 2 YA6 15 (1) (2) 30/04/07 3 YA6 12 (1) 13 (4) 13(4)(a-c) 31/03/07 4 YA9 31/03/07 5 YA18 13 (4) 12(1) a, b 12 (1) a, b 13 (4) 30/04/07 6 YA23 30/04/07 7. YA33 YA13 18(1)(a) 31/03/07 Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 27 The number of staff provided must be adequate to enable service users to undertake activities of their choice, consistent with their peers. 8 YA37 8 9 13 (4) a, b, c The manager must make application to the CSCI for registration. The general risk assessment for the environment must be developed and kept under review. 31/03/07 9 YA42 31/03/07 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. 2. 3 4 5 6 7 8 9 Refer to Standard YA1 YA6 YA8 YA13 YA17 YA20 YA22 YA23 YA37 Good Practice Recommendations It is recommended that the provider produces the service user guide in a format accessible to service users. It is recommended that Person Centred Planning be undertaken with all service users to address peoples changing needs and aspirations. It is recommended that information about service users be presented in an accessible format. It is recommended that the arrangements for the funding of activities be reviewed. It is recommended that menus are monitored to ensure that five fruit and vegetables are offered. It is recommended that a photograph of each service is in front of the medication record sheet and includes details about how service users like to take their medication. It is advised that the complaints procedure is produced in a format suitable for service users. It is advised that a log of regulation 37 is kept so that there is a clear audit trail of information. It is advised that the allocated management hours are reviewed. DS0000065003.V317388.R01.S.doc Version 5.2 Page 28 Kingsbury Road, 228 10 YA42 It is advised that details of staff involved in fire drills are kept so that manager can ensure all staff have this opportunity of implementing the fire safety procedure. Kingsbury Road, 228 DS0000065003.V317388.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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