Inspection on 23/09/05 for The Laurels

This inspection was carried out on 23rd September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 46 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 15/02/06

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 23rd September 2005 09:45 Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 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.V253820.R01.S.doc Version 5.0 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.V253820.R01.S.doc Version 5.0 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.V253820.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 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. 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. 31st January 2005 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.V253820.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process records pertaining to residents, Health and Safety records and Polices and Procedure were sampled. Discussion with residents, staff and management formed part of the information contained in the report. A tour of the building including resident’s bedrooms was seen. Two inspectors completed an unannounced visit to the Laurels. Issues of concern were raised with the Team manager. A meeting has been arranged with the Team Manger and CSCI to discuss the concern identified during the visit. 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.V253820.R01.S.doc Version 5.0 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.V253820.R01.S.doc Version 5.0 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, 2, 3 The absence of important information, including written needs assessments potentially puts residents at risk of harm and means that resident’s needs may not be met. Initial assessments are not up dated to ensure the residents’ needs are met. EVIDENCE: It was disappointed to note the Service Users’ Guide and Statement of Purpose was not completed. The manager gave the inspector a copy of the draft. Considering only minor amendments were required from the last inspection the document still contained underlined information that required deleting or amendment. The Manager sent an action plan to the Commission giving a time scale when this would be completed this being 01 May 2005. The Manager said “ We rely on the social worker providing us with information to be able to make the decision if we can meet residents needs’’. A document sampled of an assessment did not give sufficient information to base a decision. Information contained in the document /care plan said provide 24 hour care. Initial assessments are not reviewed, monitored or evaluated. Individual assessments are not completed. One resident had recently been admitted. A previous home had given as much information as they could, however no assessment had been completed since. Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 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, 9, 10 The care planning system is not clear and consistent and does not provide staff with the information they need to meet resident’s needs. Risk assessments are not completed to protect residents from harm. Polices and procedure are clear but the implementation is inconsistent resulting in unsafe practices. EVIDENCE: Information in care plans was insufficient, not up to date and had not been reviewed. There was a lack of robust risk assessments for moving and handling, behaviour strategies and the environment. Both staff and residents safety and well being is potentially put at risk. ISS Individual Service Users Statements had not been reviewed. One had been implemented in 1998; no review had been completed since this date. The manager said “ nothing has changed in this residents daily living’’. This file was sampled there was clear evidence this residents had an eating disorder and professional guidance was available but not adhered to. The instruction was staff should sit with this resident during mealtimes to prompt him to eat his meals. Instructions from the Community Nurse, relative and staff from the day centre he attends clearly said this worked. There were no records to say staff adhered to these instructions. When the inspectors asked the manager, the manager said “ this does not work’’. There were no records to support this statement. One Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 9 resident who had recently been admitted required a one to one carer recent strategies had been put in place from the previous home including strategies for Challenging behaviour. In daily records an entry stating possible risk assessments needed and a coping strategy for this resident. This clearly demonstrates the lack of communication between management and staff. Risk assessments had been completed by the previous home including a risk assessment for the environment. The resident had been in the home for over a week and the risk assessments had not been adapted to the current environment or situation. Emergency admission may be necessary; however there is no regard paid to the potential disruption this may have on other residents. There are no records to show care is taken to ensure that the balance of life is not disturbed unduly by the presence of the residents being admitted without the correct information being obtained. Staff said residents make decisions on a daily basis about food going out or what activities they would like to do. Records were not sampled. Confidentiality is not maintained. Information pertaining to an allegation of abuse was recorded inappropriately for all staff to see. Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 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): 16, 17 Resident’s rights and choice are respected. Staff give support when required. A well-balanced and nutritional meal is provided. The cleanness of the kitchen is poor. Infection control is not maintained to a satisfactory standard and could contribute to residents being placed at risk. EVIDENCE: Staff were seen to interact with resident with respect and in an appropriate manner. One resident said he makes decisions for himself and staff support him. Observation made indicated residents had a very good rapport with staff. Menus sampled indicated a nutritional meal was provided with a second choice. The kitchen area in parts was dirty, photo were taken. Infection control was very poor. Staff were seen coming into the kitchen without washing their hands. The sink in which staff should wash their hands was being used to prepared vegetables. Paint was pealing off the walls and draws contained different items such as gloves dirty cloths and utensils. A cupboard that contained cups and plates was dirty leaving a residue on the cups. The kitchen had a flycatcher that had not been cleaned for some time and contained a Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 11 large number of dead insects. Kitchen sinks required deep cleaning as they were stained. Requirements made by the Environmental Health had not been completed. Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 12 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 There is not sufficient information to show how residents achieve their full potential, capacity, physical, and intellectual needs while on respite. There is insufficient information for long stay residents to indicate the above. Records pertaining to the health and welfare of residents are not adequately recorded. EVIDENCE: Regular reviews of resident personal needs, objectives, and health care do not take place. Risk assessments are inadequate and do not give details of how risks are to be managed minimised or up to date. Records do not show how residents are involved in the plan of care. The initial assessments procedure does not prevent admission of residents who by the nature or degree of their disability are unsuitable and beyond the capabilities of staff. Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 13 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 Residents participate in meetings on a regular basis. When a complaint is made confidentially, information is not stored securely and access is available to all staff. This could lead to repercussion to the complainant. EVIDENCE: Meetings take place where residents can air their views. The minutes of these meeting were not examined in detail. When a complaint is made, information is recorded. Further development is required in recording signification information such as time, date and response. It was concerning to see information pertaining to a possible allegation of abuse was recorded in the residents daily records for the perpetrator to see. This is totally unacceptable as the residents are open to further repercussion form the perpetrator. Confidentiality is certainly not maintained in this instance. This information must be removed and recorded appropriately in accordance with polices and procedure and Adult Protection Guidance. Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 14 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, 30 The environment could be improved with decoration. Resident’s bedrooms are not homely and personal. In general, the home was clean. Robust procedure must be in place for the cleaning of the kitchen area as the health of residents could be put at risk. EVIDENCE: Decoration is required in resident bedrooms. Bedrooms are not homely in appearance and comfortable. The manager said “ Resident do not bring in personal belonging due to them being on respite’’. The bedrooms are basic in appearance and do not have suitable furnishings such as tables, chairs and wardrobes. The pillows are worn and lumpy. There are not sufficient provisions for resident’s personal possessions and hanging space for clothing. The Statement of Purpose does not give a true reflection of the accommodation. Such as eight bedrooms have built in wardrobes. These wardrobes have curtains as doors as there is insufficient space for a door to be opened. Bedrooms do not have all the furnishing required by this Standard. In general, the home was clean. The Kitchen area needs to be addressed and strict robust cleaning procedures put in place. Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 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): 32, 35, 36 Training records need significant improvement to identify staff competences and development. Supervision is not completed. This must improve to ensure staff are aware of their roles and responsibilities. EVIDENCE: Training records were not up to date. The manager had commenced a training matrix to enable him to identify the short fall in staff development. It was unclear what staff competences were at the time of inspection. The inspectors did not examine staff files during the visit. The manager said supervision records had not been completed on a regular basis and were not up to date. The manager was in the process of updating all staff files with supervision in line with identifying staff training needs. Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 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 Residents are not protected by polices and procedure as there is a significant lapse in implementation. Care plans are not reviewed, Risk assessment are not updated and residents views or concerns are not protected under polices and procedure for confidentiality. EVIDENCE: Records pertaining to Gas Safety, Fire Safety and lifting equipment were in date. Risk assessment for all service users must be reviewed and documented to specify if the risk is being managed, who could be harmed and the seriousness. Fire safety records indicate that weekly test and drills are completed. There are clear polices and procedure for the protection of residents that are not implemented and include Complaints, Adult Protection, Supervision, Training, and Risk Assessments. All outstanding requirements from the last inspection must be completed. Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 1 1 X X Standard No 22 23 Score 1 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X X 1 1 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 1 X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X X 1 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Laurels, The Score 1 1 X X Standard No 37 38 39 40 41 42 43 Score 1 X X X X 2 X DS0000033658.V253820.R01.S.doc Version 5.0 Page 18 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,b,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 - Non Compliance 2 YA1 5(1) The registered person must 01/12/05 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 - Non Compliance 3 YA2 14(2)(1) 14(2)(a,b) 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. DS0000033658.V253820.R01.S.doc Timescale for action 01/12/05 01/03/06 Laurels, The Version 5.0 Page 19 4 YA3 14(2)(1) The Registered Person must demonstrate the home’s capacity to meet the assessed needs of residents, by ensuring care plans are reviewed in full consultation with the residents. 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 01/05/05 - Non Compliance 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 01/05/05 - Non Compliance The registered person must ensure that only service users whose main identified needs are those linked to their learning disability are admitted to the home. Previous time scale 01/05/05 - Non Compliance 01/03/06 5 YA3 12(1)(a) 01/04/06 6 YA3 14(1)(a,b,d) 23(2)(d) 01/02/06 7 YA3 16(1) 01/02/06 8 YA4 12(1)(a) The Registered Person must ensure that preadmission visits to the home are recorded and the assessment carried out at these visits is recorded. 01/02/06 Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 20 This standard not inspected. 9 YA5 5(1)(b,c) 01/02/06 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. This standard not inspected. 10 YA5 12(2) The Registered Person must ensure that service users are involved and are provided with the appropriate support when drawing up the contract. This standard not inspected. 11 YA6 15(1) The registered person must 01/02/06 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 01/05/05 - Non Compliance 12 YA6 15(2)(b) 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 DS0000033658.V253820.R01.S.doc 01/02/06 01/02/06 Laurels, The Version 5.0 Page 21 within one week of admission. When admitting service users in an emergency as soon as possible. Previous time scale 01/05/05 - Non Compliance 13 YA6 14(2)(a,b) Care plans must provide instructions to staff on how to respond to inappropriate behaviour. Previous time scale 01/05/05 - Non Compliance 14 YA6 15(1)(2) 01/02/06 Care plans must be detail how resident’s needs are to be met. Where appropriate it is impracticable to carry out consultation with the resident an alterative representative must be consulted. Review must take place. 01/02/06 01/02/06 15 YA6 15(2)(c) 16 YA9YA42 13(4)(a,b,c) The registered person must 01/02/06 ensure that all risk assessments for service users are comprehensive, dated and regularly reviewed. Previous time scale 01/01/05 - Non Compliance 17 YA42 13(4)(c) 14(2)(a,b) Risk assessments in general must be up to dated for the building and include the degree of risk for who could be harmed, and the seriousness. Previous time scale 01/01/05 - Non Compliance DS0000033658.V253820.R01.S.doc 01/02/06 Laurels, The Version 5.0 Page 22 18 YA10 13(4)(c) Information pertaining to residents must remain Confidential at all times. Evening, weekend and recreational activities (in house 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. The Registered Person must ensure that service users have a nutritional assessment that is regularly reviewed. Previous time scale 01/01/05 - Non Compliance 01/02/06 19 YA12 16(2) 18(1a) 24(1a,b) 01/02/06 20 YA17 17(1a) Sch3 (3m) 01/02/06 21 YA17 13(4)(c) The Registered Person must complete an audit of all food in the home and ensure the cleaning of the kitchen is robust. Previous time scale 01/01/05 - Non Compliance 01/02/06 22 YA17 13(4)(c) The Registered Person must ensure residents are not placed at risk of cross infection. Significant information must be available to show how the identified needs of residents are met. The health and welfare of residents must be DS0000033658.V253820.R01.S.doc 01/02/06 23 Y A18 14(1a,b,c) 01/02/06 24 YA19 15(2a,b,c) 01/02/06 Laurels, The Version 5.0 Page 23 monitored and reviewed. 25 YA22 22(3) All complaints must be fully investigated and remain confidently The Registered Person must ensure the protection of residents in all matter relating to health and welfare, complaints and concerns raised. All parts of the building must be in a good state of repair. The handle in the kitchen that is broken must be repaired. All bedrooms must be decorated to a satisfactory standard. All parts of the kitchen area must have robust cleaning procedure in place. The Registered Person must keep the CSCI informed of the progress on plans for the redevelopment of the service. This standard not inspected. 31 YA26 4(1) 5(1) The Registered Person must 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. This standard not inspected. 01/02/06 01/02/06 26 YA23 23(2)(b) 01/02/06 27 YA24 23(2)(b) 01/02/06 28 YA24 23(2)(b) 01/02/06 29 YA25 13(4)(c) 01/02/06 30 YA25 12(1) 01/02/06 Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 24 32 YA26 12(4)(a) The Registered Person must ensure that all bedrooms have a lockable facility. This standard not inspected. 01/02/06 33 YA26 12(4)(a) 01/02/06 The Registered Person must ensure that any bedrooms without a wash hand basin or en-suite facilities are provided with adequate washing facilities. This standard not inspected. 34 YA29 23(2)(n) The Registered Person must ensure that there is a system in place that enables service users and staff to summon assistance throughout the home. This standard not inspected. 01/02/06 35 YA30 13(4)(c) All COSHH Data sheets must be updated. This standard not inspected. 01/02/06 36 YA30 13(4)(c) Infection control must be maintained and monitoring checks completed in the kitchen area to prevent residents being placed at risk. The Registered Person must ensure that an alternative site for the laundry is identified. This standard not inspected. 01/02/06 37 YA30 13(3) 01/02/06 38 YA32 18(1)(a,b,c) All mandatory training must be completed and 01/02/06 Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 25 records available for inspection. 39 YA35 18(1)(c)(i) The Registered Person must ensure that all staff undertakes induction training within six weeks of taking up employment. Previous time scale 01/05/05 - Non Compliance 40 YA35 18(1)(i) Refresher course in all mandatory training must be provided. Previous time scale 01/05/05 - Non Compliance All staff must receive training in managing challenging behaviour. Previous time scale 01/05/05 - Non Compliance 42 YA35 18(1)(i) All staff must receive training to the work they perform. Confirmation of completion must be available. The Registered Person must ensure that all staff receives a minimum of six supervision sessions a year. Previous time scale 01/01/05 - Non Compliance 44 YA37 13(4)(c) The Manager must ensure all polices and procedures are implemented to protect resident’s welfare and wellbeing. 01/02/06 01/02/06 01/02/06 01/02/06 41 YA35 18(1)(i) 01/02/06 43 YA36 18(2) 01/02/06 Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 26 45 YA39 15(2)(c) The registered person must 01/02/06 ensure that there is a quality monitoring system in place that seeks the views of those using the service. Previous time scale 01/01/05 - Non Compliance 46 YA42 13(4)(c) All care plans risk assessments pertaining to residents must be reviewed. 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Laurels, The DS0000033658.V253820.R01.S.doc Version 5.0 Page 27 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.V253820.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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