Inspection on 06/06/06 for The Laurels

This inspection was carried out on 6th June 2006.

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 29 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 15/02/06

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 6th June 2006 09:00 Laurels, The DS0000033658.V288965.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.V288965.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.V288965.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.V288965.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 NCSC for the future of the service by end of September 2004. 15th February 2006 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.V288965.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection was completed including one day of fieldwork by two inspectors. Records pertaining to the health and welfare of residents were sampled, including daily records, risk assessments, Health Action plans, activity records, and care plans. Throughout the inspection, the manager and acting manager were present. The inspectors did not have the opportunity to speak with residents on a one to one basis but general discussions with residents were held throughout the day. Observations made showed staff interacted with residents well. What the service does well: What has improved since the last inspection? What they could do better: During the last inspection, a number of requirements were made pertaining to care records, risk assessments, health action plans, activity records, and documentation of how the staff at the Laurels would meet the resident needs, aims, and objective. It was extremely disappointing to see no progress had been made with the reviews of individual residents care plans risk assessments, activity records or reviews. The manager had been on extended leave and an acting manager had been appointed on a secondment basis. The manager said 15 care plans ISS had been completed and all risk assessments had been done. When inspectors asked to see a comparison to the records, they were sampling no care plans ISS or risk assessment were produced. This request was asked repeatedly. At the end of the visit, the inspectors could not evidence a comparison of completed reviews of care records. The records sampled were poor and did not show how resident’s needs were met Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 6 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.V288965.R01.S.doc Version 5.1 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 Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Information contained in the Statement of Purpose is not adequate. Assessments of residents needs are not adequate. EVIDENCE: Assessments are not completed. The admission procedure was not available. The manager said “when we receive a call from the Social Worker we take the details down to see if we can meet the person needs, then we phone the team manager who is in the same office at the social workers, they then make the decision’’. An assessment is not completed once the residents come into respite. The manager said “ we work from the social workers care plan’’. While this is acceptable if the information is detailed, the manager must complete his own assessments when the resident comes into the home within 72 hours particular risk assessments pertaining to the environment. The Statement of Purpose has been developed further. The manager attention is brought to Schedule 1 of the (NMS) National Minimum Standards all the information in this Schedule must be incorporated into the Statement of Purpose. The manager must ensure requirements outstanding from the last inspection are address. Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 9 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans, risk assessments do not show resident are protected. Healthcare is not monitored adequate. Religion and cultural beliefs are not maintained. Failure of producing adequate risk assessments places residents at risk. EVIDENCE: Individual Service Users Statements/ care plans, meal records, daily records, and risk assessments, were sampled for three residents. No reviews had been completed. One file showed the resident had problems with eating and was to be monitored. The religion of the resident was muslin. The monitoring records had not been completed with this information. The food records had not been completed appropriately to identify what the resident had eaten and how often as this resident would often skip meals. The meal the resident had received on one particular day indicated he had eaten pork. In the resident notes, it clearly said no pork. The consequence of this could have a devastated effect on the person and their faith. The Laurels are clearly not meeting the resident cultural needs. Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 10 One resident had an allergy to nuts, penicillin, and amoxicillin. There were no risk assessments in place. When inspectors spoke with the cook, she was unaware of this allergy. This could place this resident at considerable risk. Information was contained in the resident’s medical records MAR Charts. Agency care staff would not have this information to hand. The team manger was contacted during the visits by the inspectors to voice their concerns. Details were requested by the inspectors to be given to the kitchen detailing people allergies. The acting manager had complied information in the form of an overview with residents likes, dislikes, and aliments. This must be incorporated into the care plans. This information was in draft format and had not been submitted to resident care plans. The information once submitted would give care staff immediate guidance about the resident. The information must be put into care plans in more detail to ensure staff have further information if required. One comment card received before the visit said the residents had difficulty in communication, reading, and writing. The resident’s file was sampled. There was no mention of the inability to read, write or how the person communicated their needs. The care plan had not been reviewed. There were no records to show how residents participated in their care plans or whether they made decisions about their daily life. Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 11 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): 12, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Daily records showed some activities the residents were able to participate in. The recording of information in an activities book as indicated by the action plan received was not available and will be assessed during the next visit. EVIDENCE: Records pertaining to residents ‘in house’ and communal activities were not available. Residents do go to the day centre on a regular basis. Residents spoken to indicated they complete activities. In daily records, information had been recorded such as playing pool or going shopping. During the last inspection, the manager said he had produced a book that shows what resident had completed on a daily or weekly basis. At the time, he did not know where this book was. The action plan returned from the last inspection indicating what action had been taken to the requirement that was made. The manager would set up an activities book in reference with CR8 to record activities, participants, and record feed back. This was to be completed by 1 May 2006. The manager said this had been completed but did not know Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 12 where it was as he had been on leave. The activities book will be sampled during the next visit. Comment cards received before the inspection from relatives and residents confirmed activities took place in the community. Food records were not completed regularly so an audit could not be completed in full. Records showed information pertaining to religion however monitoring of choice on food to residents for religious reasons was not monitored. One resident only eats Halal meat; records indicated the resident had eaten pork. There was no evidence to show this had been his decision. The information recorded in his care plan clearly stated no pork. Other food records sampled were incomplete. Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 13 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Monitoring of residents health care needs significant improvement. If the manager is on annual leave, a designated person must be identified to ensure the needs of residents are met. EVIDENCE: Files sampled pertaining to resident’s health care needs did not show how resident’s needs were met. Information recorded indicated when an aliment was diagnosed appropriate action was not taken. For example, one resident required monitoring with food intake. The records were incomplete. One resident had an allergy to nuts and soya products however there were no risk assessments in place. The records did not show how this was monitored, review, or a risk assessment completed. The lack of information places the residents a risk. The manager must review the care plan and ensure significant information is available to staff. Daily records show residents attended health care appointment such as doctors and hospitals. The recording of residents’ weight when a problem had been identified was not available. The manager was asked for this information. The manager said he had not received a handover from the acting manager since he had returned from annual leave. The acting manager said he had concentrated on providing Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 14 information to staff to ensure they had an overview of residents likes dislike and aliment. He had looked at the information that was currently recorded and felt this was adequate and needed to concentrate on providing further information. This information will assist with the development of the care. It is unacceptable that residents need, care plans, health records risk assessments had not been completed since the manager went on annual leave. Care plan still need to be up to dated, inspective of whether the manager is on annual leave. If additional information is required, a full review must take place. Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 15 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 Quality in this outcome area is good pertaining to complaints. Quality in this outcome area pertain to protection is poor. This judgement has been made using available evidence including a visit to this service. Records demonstrate all complaints are fully investigated and action taken. Risk assessments are not completed for all aliments. Risk to resident health is greatly increased by lack of information recorded. EVIDENCE: Complaints records were sampled. Evidence was seen that showed all complaints are fully investigated and the outcome recorded. It is recommended that compliments are place in the complaint folder so a balance can be made. Comment cards received before the inspection gave some positive feedback. For example: “I like coming to The Laurels staff are very kind they listen to what you say and help if they can”. The Laurels use the Birmingham Agency Guideline for Adult Protection. The manager said there have been no issues surrounding Adult Protection. A letter had been received the day of the visit. Identifying some concerns for the manager to address. Risk assessments records sampled do not protect residents’ well being. Risk assessments are out of date, and do not address issues such as allergies. The lack of information recorded pertaining to residents’ needs, health and well-being place residents at risk. Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 16 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Refurbishment of the laurels has commenced. This will make the home more inviting to residents. Bedrooms do not meet the NMS guidelines. The two bedroom sampled look clean and fresh. Corridors were being decorated at the time of the visit and will be assessed at the next visit. EVIDENCE: Internal work had commenced with the decoration of bedrooms, communal areas, and the refurbishment of the kitchen. The manager said the smoke room had been changed into a kitchen for resident to use. Sinks had been put into bedrooms one to ten. The activity room is still being used as a storeroom. The planed work was to take out the both baths upstairs and have shower cubicles fitted. A tour of the building was not completed and will be undertaken at the next visit. Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 17 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, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements had been made with the commencement of a training matrix. The manager will ensure the matrix is up to date and nominate staff for training in areas pertaining to the work they perform. EVIDENCE: Training records had not been updated. The manager said staff had received some training and he needed to update records with this information. Records did not show if staff had received training in Adult Protection or Fire Safety. The manager said some staff had completed this training but he had not yet up dated the training matrix. The manager must update training records. Staff files sampled did not contain this information. Certificate on file showed training in Manual Handling and in First Aid in 2003. The manager had commenced a training matrix; this will enable the manager to identify when staff need refresher courses once it has been completed. Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 18 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, 39, 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager must ensure records are up to date, cross reference with daily records and know at all time where the information pertaining to resident is kept. EVIDENCE: The manager had returned from extended annual leave only a few days before the visit. The manager said he had not received a handover from the acting manager and was due to have one the next day. Both the manager and acting manager assisted the inspectors thought-out the visit. When the inspectors asked for information on numerous occasions neither the manager and acting manager could provide records for risks, assessments reviewed care plans, activity records or a list of tasks that had been delegated to staff. Both managers said they were unsure where these documents were. Delegation had been given to other staff member to complete these tasks. The inspectors requested a list of persons who had been given certain tasks to Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 19 complete. Neither the manager nor acting manager produced this list. When the inspectors asked for care plans to do a comparison to the records they were sampling these could not be produced. The manager said these had not been completed and no further progress had been made since the last visit to The Laurels. The manager must ensure he priorities his management responsibilities to ensure staff have clear instructions and there is a clear line of accountability. If tasks have been delegated to other duty manager and care staff then the manager must ensure dead lines and target are met. Records to show how resident’s views were sought were no recorded. The manager said he recorded all feed back from resident in the activity book that could not be found. There were no quality assurance records produced. All statutory testing of equipment used at the Laurels had been completed. Comprehensive risk assessments of the building had been completed. Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 1 14 1 15 1 16 1 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 X X 1 X 1 X X 3 X Laurels, The DS0000033658.V288965.R01.S.doc Version 5.1 Page 21 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 Timescale for action 01/08/06 2 YA2 14(2)(1) 14(2)(a,b) 3 YA3 14(2)(1) 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, May 2005, December 2005 and May 2006(Partly met) A full assessment must 01/08/06 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. Previous time scale March 2004, May 2005, December 2005 and May 2006 (Partly met). The Registered Person 01/08/06 must demonstrate the home’s capacity to meet the assessed needs of residents, by ensuring care plans are reviewed DS0000033658.V288965.R01.S.doc Version 5.1 Page 22 Laurels, The 4 YA3 12(1)(a) 5 YA3 14(1)(a,b,d) 23(2)(d) 6 YA3 16(1) 7 YA4 12(1)(a) 8 YA5 5(1)(b,c) in full consultation with the residents. Previous time scale March 2004, May 2005, December 2005 and May. Not assessed. 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 timescale May2005 – 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 timescale May2005 – not assessed. 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 timescale May 2005- not assessed. The Registered Person must ensure that preadmission visits to the home are recorded and the assessment carried out at these visits is recorded. Previous timescale May 2005 This standard not assessed. The Registered Person must ensure that each service user is given a contract/statement of DS0000033658.V288965.R01.S.doc 01/08/06 01/08/06 01/08/06 01/08/06 01/08/06 Laurels, The Version 5.1 Page 23 9 YA5 12(2) 10 YA6 15(1) 11 YA6 15(2)(b) 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 May 2005- This standard not assessed. The Registered Person must ensure that service users are involved and are provided with the appropriate support when drawing up the contract. Previous timescale May 2005 This standard 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 timescale March 2004, May 2005, December 2005 and May 2006 (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 timescale March DS0000033658.V288965.R01.S.doc 01/08/06 01/08/06 01/08/06 Laurels, The Version 5.1 Page 24 12 YA6 14(2)(a,b) 13 YA6 15(1)(2) 14 YA6 15(2)(c) 15 YA9 13(4)(a,b,c) 16 YA12 16(2) 18(1a) 24(1a,b) 2004, May 2005, December 2005 and May 2006 (Partly met). Care plans must provide instructions to staff on how to respond to inappropriate behaviour. Previous timescale May 2005 and February 2006 Non Compliance. Care plans must detail how resident’s needs are to be met. Previous timescale March 2004, May 2005, December 2005 and May 2006 (Partly met). Where appropriate it is impracticable to carry out consultation with the resident an alterative representative must be consulted. Review must take place. Previous timescale March 2004, May 2005, December 2005 and May 2006 (Partly met). The Registered Person must ensure that all risk assessments for service users are comprehensive, dated and regularly reviewed. Previous timescale March 2004, May 2005, December 2005 and May 2006 - Non-Compliance. 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 DS0000033658.V288965.R01.S.doc 01/08/06 01/08/06 01/08/06 01/08/06 01/08/06 Laurels, The Version 5.1 Page 25 17 YA17 17(1a) Sch3(3m) 18 YA18 14(1a,b,c) 19 YA23 23(2)(b) 20 YA24 23(2)(b) 21 YA26 4(1) 5(1) enable any person inspecting the records to verify the level and range of activities. Previous timescale February 2006 - Noncompliance. The Registered Person must ensure that service users have a nutritional assessment that is regularly reviewed. Previous timescale May 2006 (Partly met) - Non Compliance. Significant information must be available to show how the identified needs of residents are met. Previous timescale February 2006. The Registered Person must ensure the protection of residents in all matter relating to health and welfare. Previous timescale February 2006 - Non Compliance. All bedrooms must be decorated to a satisfactory standard. Previous timescale March 2004, May 2005, December 2005 and May 2006 (Partly met). 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. Previous timescale March 2004, May 2005, December 2005 and May DS0000033658.V288965.R01.S.doc 01/08/06 01/08/06 01/08/06 01/08/06 01/08/06 Laurels, The Version 5.1 Page 26 2006 (Partly met). 22 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. Previous timescale February 2006 - Non Compliance. The Registered Person must ensure that an alternative site for the laundry is identified. Previous timescale March 2004, May 2005, December 2005 and May 2006 - Non-Compliance. All mandatory training must be completed and records available for inspection. Previous timescale February 2006 - Non Compliance. Refresher course in all mandatory training must be provided. Previous timescale May 2005 and February 2006 - Non-Compliance. All staff must receive training in managing challenging behaviour. Previous timescale May 2005 and February 2006 - Non-Compliance. The Registered Person must ensure that there is a quality monitoring system in place that seeks the views of those using the service. Previous timescale January 2005 and February 2006 not assessed. DS0000033658.V288965.R01.S.doc 01/08/06 23 YA30 13(3) 01/08/06 24 YA32 18(1)(a,b,c) 01/08/06 25 YA35 18(1)(i) 01/08/06 26 YA35 18(1)(i) 01/08/06 27 YA39 15(2)(c) 01/08/06 Laurels, The Version 5.1 Page 27 28 YA19 13(4) 29 YA19 13(4) The Registered Person must ensure information is documented pertaining to allergies. The Registered Person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. 01/08/06 01/08/06 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.V288965.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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