Inspection on 15/02/06 for The Laurels

This inspection was carried out on 15th February 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 38 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Laurels 14/07/08

The Laurels 02/07/07

The Laurels 22/11/06

The Laurels 06/06/06

The Laurels 23/09/05

The Laurels 31/01/05

The Laurels 27/10/04

The Laurels 23/03/04

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 Laurels, The 65 Frederick Road Stechford Birmingham B33 8AE Lead Inspector Susan Scully Unannounced Inspection 15th February 2006 09:00 Laurels, The DS0000033658.V283954.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 Laurels, The DS0000033658.V283954.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. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Laurels, The Address 65 Frederick Road Stechford Birmingham B33 8AE 0121 784 5222 0121 784 5232 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) Social Care and Health Warren Mark Powell Care Home 17 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (1) of places Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered to accommodate 16 adults under the age of 65 and 1 adult over the age of 65, all in need of care for reasons of learning disability. That minimum staffing levels are 7.00am - 10.00pm 3 care assistants and a suitably qualified and competent designated shift leader. The Care Managers hours must be supernumerary to care hours. A fence is erected between the garden of the home and the day centre in the bungalow in the garden by 30th June 2004. Service users are admitted to the home for respite care and not longterm care. Long-Those residents who have been at the home for a longer period will be found alternative appropriate places at the earliest opportunity. A programme for planned maintenance and renewal is implemented by 30th June 2004. Plans for the re-provision of the service will be agreed with the CSCI for the future of the service by end of September 2004. 23rd September 2005 2. 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: The Laurels is a large two-storey purpose built Local Authority Home, accommodating up to 17 adults who have a learning disability on a respite basis. The Home has nine ground floor bedrooms and the remainder of the bedrooms are on the first floor, which can be accessed via a shaft lift. There are a number of communal areas on both floors. There are bathroom and toilet facilities on both floors. The Home does not meet the National Minimum Standards in terms of accommodation provided. All but two bedrooms are below minimum spatial standards. Five bedrooms are without wash hand basins. The number of toilets is not adequate for the number of service users accommodated. The Home is situated in a quiet cul-de-sac in Stechford, close to local shopping facilities, a train station and bus routes. To the front of the building is a car park area and to the rear is a garden. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place over a one-day period. Records were sampled pertaining to residents daily records, care plans, risk assessments and Healthcare needs. Other records seen include staff files, Health and Safety records, Policies and Procedures and records pertaining to staffing levels. What the service does well: What has improved since the last inspection? 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. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 6 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 Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Accurate information is not available for residents to make a judgment as to whether to use the service. EVIDENCE: The Statement of Purpose does not give an accurate reflection concerning the environment. Information contained indicates all bedrooms have all the required furnishing such as easy chair, chest of draws, bedside cabinet and bedside lamps. During the visit, bedrooms were seen and did not contain an easy chair and bedside lamp. In two rooms the overhead lights for the mirrors were not working. The Statement of Purpose also states there is a facilities for residents to prepare hot and cold drinks. This facility has not been available over the last two inspections. Currently it is being used, as a storage room while the down stairs kitchen is not functional. The representative at the time of the visit said this is for a limited time. Other information includes setting objectives that are specific to the individuals. Individual information in residents files sampled indicates this has commenced. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Comprehensive care plans have not been completed but progress has been made in respect of reviewing all care plans. Care plans do not state or show how residents are involved in the drawing up of all their needs goals and aspirations. Risks assessments must be completed for all residents. EVIDENCE: Care plans at the last inspection gave little or no information pertaining to residents needs. Two care plans were sampled during the visit information contained in the one care plan had improved. Information consisted of a personal profile, risk assessment, and an updated care plan (individual service users statement). Needs had been identified but did not cross reference to the daily records. For example recorded on the personal profile of one resident, specified the resident required full support. Information had not been transferred to the care plan (individual service users statement) of what support was required or what the resident could do for himself. There was no evidence to show the residents had been involved in drawing up of the care plans. Issues surrounding diet did not identify meals that were missed or requests for different foods pertaining to culture needs. A further entry in the care plan (individual service users statement) indicated one resident had communication needs, information did not reflect what communication Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 9 methods were used or what the communications needs were. Behaviour was also indicated concerning food that the residents refused to eat; no evidence was available to say how this was managed. Other information on other behaviour issues concerning residents gave good information to staff indicating what to do and the approaches to take. A balance needs to be implemented to complete a tracking system to be able to ensure all records cross-reference. Staff said they were in the process of completing all ISS. Discussions had taken place with CSCI, Team Manager Birmingham City Council and The manager of The Laurels. It was pleasing to see progress had been made in the development of individual care plans to identify current needs of the residents. When completing an update of care plans (individual service users statement) Care plans should give greater detail to the degree of help required and tailored to individual needs. Risk assessment had been completed on the two files sampled. Information however did not cross reference to care plans. One care plans showed the resident suffers with epilepsy; there was no risk assessment. Staff said this was the only risk assessment that had not been completed. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 10 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): 14, 16 Choices and individual preferences are met for most residents, but activities do not meet all residents’ expectations, preferences and capacities. EVIDENCE: Most residents are able to express choices in their daily lives and activities are encouraged and supported. Recent staff shortages have had an impact on what activities the resident can participate in. For example, daily tasks such as cooking or general household duties such as shopping. Residents who are less able to communicate what activities they want to do staff must ensure these are not overlooked. For example one residents activity was to listen to music and go out for walks, there was no records to show these activates had taken place and the resident would not be able to express the desire. These activities have an implication on staffing. Residents interact positively with staff. Staff are respectful to residents choices. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 11 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): 19, 20 Records pertaining to the Health and Welfare of residents have improved. Further developed is required to show how all records are incorporated into individual care plans. Medication records must be audited on a regular basis and omissions and discrepancies identified must have a written explanation. EVIDENCE: Improvements have been made with the recording of information concerning resident health needs. There is some way to go however but it was pleasing to see the improvements already made. Files sampled gave information of healthcare appointments with other professionals and what action if any was required. Recent reviews had been completed on those files sampled. Records do not show how residents are involved in the plan of care. This is an area where management must improve on. Care plans (Individual service users statements) must cross reference with the goals, aspiration and needs of residents. Medication records were in general satisfactory; an audit was completed with some minor areas identified in the recording methods. All written entire must be verified with two signatures. All medication must be accounted for, where there is a discrepancy an account of why must be recorded. Regular audit must be completed with a full tablet count. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 12 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): Standards not assessed. No judgement. EVIDENCE: No evidence sampled. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 13 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 The Laurels does not present a homely environment. Furniture is worn and décor is very poor with large cracks in walls and torn wallpaper in resident’s bedrooms. EVIDENCE: The environment is in a very poor decorative condition; corridors and bedrooms are dismal in appearance. Residents bedrooms are not homely and do not provide a comfortable surroundings for residents. Wallpaper and borders are ripped or torn. In some bedrooms where water has leaked from the roof dark patches and cracks have appeared. These areas have not been decorated which has left the home in a poor decorative condition. Corridors have large cracks in the plaster where there has been damaged caused. Following a visit by the Environmental Health and the closure of the Kitchen, a new Kitchen has been installed. In communal areas and bedrooms, curtains tracks are hanging down or the rooms have no facilities for draw curtains to be provided for privacy. There is a planned programme of refurbishment for The Laurels, however in the interim period the provider must ensure the environment is clean and of a suitable standard as indicated in the Statement of purpose. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 14 It is not acceptable to expect resident to live in such dismal conditions. It is recommended all prospective residents have the opportunity to visit The Laurels before making a decision to use the service. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 15 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): 34 Information is not available to confirm residents are protected by the homes recruitment practises. EVIDENCE: Recruitment files sampled showed the same issues repeatedly identified concerning information not being held in the home. All records pertaining to the recruitment of staff are held at Birmingham City Council head office. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 16 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, 42 The management structure is not adequate and measure must be taken to ensure an acting manager is in post while the registered manager is on leave. Risks assessments for the environment are not review on a regular basis. EVIDENCE: The manager is away on extended leave, at the time of the visit staff said they were finding is difficult to ensure staffing levels were maintained. There are 202 hours vacant and 170 either sick leave or holidays giving a total of 310 care hours The Laurels needs to cover. An acting manager has been identified but the start date has been put back. Staffing levels have an impact on activities for residents and staff are feeling the strain. At the time of writing the report, staffing levels have been maintained in accordance with condition of registration. If staffing levels fall below these requirements the manager representative must inform the Commission for Social Care inspection. Considering the staff shortages, there has been improvement in the management of The Laurels. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 17 The concern is if the staffing levels have an impact on the improvements already made. There are a number of risk assessments for the building. The risk assessments have not been reviewed so an accurate audit could not be completed. Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 18 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 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 X 23 X ENVIRONMENT Standard No Score 24 1 25 X 26 1 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 1 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 X 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 X 2 X X X X 2 X Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4(1)(a-c) Requirement The Registered Person must ensure that the Statement of Purpose includes all the information required by Schedule 1 of the Care Homes Regulations. Previous time scale March 2004 and 01 December 2005. Non compliance. The registered person must ensure that the service user guide includes information regarding the role of the CSCI in the complaints process and how the CSCI can be contacted. Previous time scale May 2005 and 01 December 2005. Compliance not assessed. A full assessment must be completed and a care plan developed from the initial assessment. The Registered Person must keep the care plan under review and revise the care plan when necessary. The Registered Person must demonstrate the home’s capacity to meet the assessed needs of residents, by ensuring DS0000033658.V283954.R01.S.doc Timescale for action 01/05/06 2 YA1 5(1) 01/05/06 3 YA2 14(2)(1) 14(2)(a,b) 01/05/06 4. YA3 14(2)(1) 01/05/06 Laurels, The Version 5.1 Page 20 5. YA3 12(1)(a) 6. YA3 14(1a,b,d) 23(2d) 7 YA4 12(1)(a) 8 YA5 5(1)(b,c) 9 YA5 12(2) care plans are reviewed in full consultation with the residents. Previous time scale 01 March 2006. Compliance partly met. The Registered Person must ensure that the service users who have been in the home on a long-term basis are found alternative placements. Previous time scale 01 May 2005 and 01 April 2006. Compliance not assessed. The Registered Person must complete a full assessment and inform the service user in writing that based on the assessment the home can meet the service user’s needs. Previous time scale 01 May 2005 and 01 February 2006. Compliance not assessed. The Registered Person must ensure that pre-admission visits to the home are recorded and the assessment carried out at these visits is recorded. Previous time scale 01 May 2005 and 01 February 2006. Compliance not assessed. The Registered Person must ensure that each service user is given a contract/statement of terms and conditions that includes the room to be occupied, terms and conditions of occupancy, the support, facilities and service to be provided, the fees charged and the rights and responsibilities of both parties. Previous time scale 01 February 2006. Compliance not assessed. The Registered Person must ensure that service users are involved and are provided with the appropriate support when drawing up the contract. DS0000033658.V283954.R01.S.doc 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 Laurels, The Version 5.1 Page 21 10 YA6 15(1) 11 YA6 15(2)(b) 12 YA7 14(2) 13 YA9 13(4)(a-c) 14 YA42 13(4)(a-c) 15 YA12 16(2) 18(1a) Previous time scale 01 February 2006. Compliance not assessed. The registered person must ensure that the service user plan is reviewed at least on a six monthly basis and any changes recorded and action taken. Previous time scale 01 May 2005 and 01 February 2006. Compliance partly met. The Registered Person must ensure that each service user has an individual service user plan that identifies the needs of the service user and how these needs are to be met by staff. For current service users this must be within one week of admission. When admitting service users in an emergency as soon as possible. Previous time scale 01 May 2005 and 01 February 2006. Compliance partly met. Information must be available to show how residents are consulted in the drawing up of care plans and be reviewed. The registered person must ensure that all risk assessments for service users are comprehensive, dated and regularly reviewed. Previous time scale 01 January 2005 and 01 February 2006. Compliance partly met. The registered person must ensure that all risk assessments for service users are comprehensive, dated and regularly reviewed. Previous time scale 01 January 2005 and 01 February 2006. Compliance partly met. Evening, weekend and recreational activities (in house DS0000033658.V283954.R01.S.doc 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 Laurels, The Version 5.1 Page 22 24(1a,b) 16 YA17 17(1a) Sch3(3m) 17 YA17 13(4)(c) 18 YA18 14(1)(a-c) 19 YA19 15(2)(a-c) 20 21 YA20 YA23 13(2) 23(2)(b) and out of house) must be made available to residents in accordance with ordinary life and the homes stated aims and objectives. A record must be kept of any such activities to enable any person inspecting the records to verify the level and range of activities. Previous time scale 01 February 2006. Compliance not assessed. The Registered Person must ensure that service users have a nutritional assessment that is regularly reviewed. Previous time scale 01 January 2005 and 01 February 2006. Compliance not assessed. The Registered Person must ensure residents are not placed at risk of cross infection. Previous time scale 01 February 2006. Compliance not assessed. Significant information must be available to show how the identified needs of residents are met. Previous time scale 01 February 2006. Compliance not assessed. The health and welfare of residents must be monitored and reviewed. Previous time scale 01 February 2006. Compliance partly met. Medication records must be audited on a regular basis with a full tablet count. The Registered Person must ensure the protection of residents in all matter relating to health and welfare, complaints and concerns raised. Previous time scale 01 February 2006. Compliance not DS0000033658.V283954.R01.S.doc 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 Laurels, The Version 5.1 Page 23 assessed. 22 YA24 23(2)(b) All parts of the building must 01/05/06 be in a good state of repair. The handle in the kitchen that is broken must be repaired. Previous time scale 01 February 2006. Non compliance. All bedrooms must be 01/05/06 decorated to a satisfactory standard. Previous time scale 01 February 2006. Non compliance. The Registered Person must 01/05/06 ensure that the shortfalls in the furniture and fittings in bedrooms and bedroom sizes are reflected in the statement of purpose and service user guide. Previous time scale 01 February 2006. Non compliance. The Registered Person must ensure that all bedrooms have a lockable facility. Previous time scale 01 February 2006. Non Compliance. The Registered Person must ensure that there is a system in place that enables service users and staff to summon assistance throughout the home. Previous time scale 01 February 2006. Compliances not assessed. All COSHH Data sheets must be updated. Compliance not assessed. The Registered Person must ensure that an alternative site for the laundry is identified. Previous time scale 01 February 2006. Compliance not assessed. All mandatory training must be completed and records available for inspection. Previous time scale 01 February DS0000033658.V283954.R01.S.doc 23 YA24 23(2)(b) 24 YA26 4(1) 5(1) 25 YA26 12(4)(a) 01/05/06 26 YA29 23(2)(n) 01/05/06 27 28 YA30 YA30 13(4)(c) 13(3) 01/05/06 01/05/06 29 YA32 18(1)(a-c) 01/05/06 Laurels, The Version 5.1 Page 24 30 31 YA34 YA35 Sch4(6) 18(1)(c)(I) 32 YA35 18(1)(i) 33 YA35 18(1)(i) 34 YA35 18(1)(i) 35 YA37 38(c) 36 YA37 13(4)(c) 37 YA39 15(2)(c) 2006. Compliance not assessed. Records pertaining to recruitment must be available for inspection. The Registered Person must ensure that all staff undertakes induction training within six weeks of taking up employment. Previous time scale 01 May 2005 and 01 February 2006. Compliance not assessed. Refresher course in all mandatory training must be provided. Previous time scale 01 May 2005 and 01 February 2006. Compliance not assessed. All staff must receive training in managing challenging behaviour. Previous time scale 01 May 2005 and 01 February 2006. Compliance not assessed. All staff must receive training to the work they perform. Confirmation of completion must be available. Previous time scale 01 February 2006. Compliance not assessed. Adequate management cover must be provided in the absence of the Registered Manager. The Manager must ensure all polices and procedures are implemented to protect resident’s welfare and wellbeing. Previous time scale 01 February 2006. Compliance not assessed. The registered person must ensure that there is a quality monitoring system in place that seeks the views of those using DS0000033658.V283954.R01.S.doc 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 Laurels, The Version 5.1 Page 25 38 YA42 13(4)(c) the service. Previous time scale 01 January 2005 and 01 February 2006. Compliance not assessed. All care plans risk assessments 01/05/06 pertaining to residents must be reviewed. Previous time scale 01 February 2006. Compliance partly met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 26 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 Laurels, The DS0000033658.V283954.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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