Inspection on 20/01/06 for Manor Park Grove, 5

This inspection was carried out on 20th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 24 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Park Grove, 5 16/10/08

Manor Park Grove, 5 28/11/07

Manor Park Grove, 5 11/07/07

Manor Park Grove, 5 01/08/06

Manor Park Grove, 5 23/08/05

Manor Park Grove, 5 22/01/05

Manor Park Grove, 5 29/09/04

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 Manor Park Grove, 5 Northfield Birmingham West Midlands B31 5ER Lead Inspector Kerry Coulter Unannounced Inspection 20th January 2006 09:00 Manor Park Grove, 5 DS0000016800.V279567.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 Manor Park Grove, 5 DS0000016800.V279567.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. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Manor Park Grove, 5 Address Northfield Birmingham West Midlands B31 5ER 0121 476 5821 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) FCH Housing & Care Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 23rd August 2005 Brief Description of the Service: 5 Manor Park Grove is a purpose built bungalow located within a quiet residential road, built upon the grounds of Rubery Hill hospital. The home is close to the local facilities of Great Park and Rubery Shopping Centre. The home is situated within a cul de sac with off street parking available. Each tenant has a single bedroom, which have been furnished and decorated to the individual taste with assistance from tenants. Each bedroom has a wash hand basin. There is a communal bathroom with an adapted bath and there is a separate shower room. In addition to a through lounge/dining room, there is a kitchen, laundry room and an office. To the rear of the home there is a pleasant garden.The home, which is registered with FCH Housing and Care currently accommodates four adults with a learning disability. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day. Three tenants, Manager and the staff on duty were spoken to. Not all tenants spoken with were able to give a view of the home due to their communication needs. A partial tour of the premises took place. Care, staff and health and safety records were looked at. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from August 2005. What the service does well: What has improved since the last inspection? Health Action Plans have been initiated. This is something that the Government paper, ‘Valuing People’ said that each person with a learning disability should have by 2005. Some good work is underway to include tenants in the care planning process. Review meetings are planned for all tenants. A photographic chart of staff enables tenants to be clear about who is their key worker. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 6 Systems of staff support have improved with staff receiving regular formal supervision and staff meetings have recommenced. 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. Manor Park Grove, 5 DS0000016800.V279567.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 Manor Park Grove, 5 DS0000016800.V279567.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): 1, 2 The Statement of Purpose needs to be finalised to ensure tenants are clear about the services the home provides to meet their needs. The admission policy and procedure requires review to reflect the National Minimum Standards. EVIDENCE: The Manager said that he was still working towards finalising the Statement of Purpose for the home, as previously required. The document is near to completion with just the addition of staffing structures and qualifications to be added. The Service User Guide was observed to be satisfactory at the inspection in August 2005. There have been no new admissions since the last inspection. It was required at the last inspection that the admission policy and procedure required review to ensure it reflects the National Minimum Standards with regards to the admission and assessment process. The policy stated that each service is to have its own admission criteria, however this was not available for the home. This has not yet been reviewed. The Locality Manager stated that the FCH is working on updating many of its policy and procedures. Manor Park Grove, 5 DS0000016800.V279567.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, 10 Individual plans need some development to ensure they are regularly reviewed, contain guidance on health needs and set goals, so that these can be measured in the future. People are supported to take responsible risks, but some work needs to be done to ensure written assessments are available for all areas of identified risks. Staff support tenants to make choices and decisions about day-to-day things in their lives. EVIDENCE: Two tenant care plans were sampled. These included tenants profiles which were generally found to be comprehensive and detail the levels of support required. Profiles also included support strategies, individual behaviour support requirements and daytime opportunities. Further information has been added to the care plan of one tenant regarding diabetes as previously required. However one plan needed further information on epilepsy to be included. The tenant profile of one individual was up to date but the other had not been reviewed for some time. The care plans need to be reviewed at least six monthly. However, progress towards this is being made and some good work is underway to include tenants in the care planning process. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 10 On the day of the inspection one tenant met with staff to review their care, dates have also been set in January and February for the remaining tenants. Discussion with the tenant indicated that they had been fully involved in their review. Members of staff were observed encouraging tenants to make choices about day-to-day matters, such as what to have for breakfast, and what they wanted to do on that day. People’s ability to exercise choice and to make informed decisions is variable, according to their degree of learning disability. Tenant risk assessments were sampled. The current system of having two risk assessments (one a copy of the original) is confusing. One set of assessments had been reviewed whilst most of the others had not. Depending on which file is viewed staff may not be reading the most up to date version. The organisation of the assessments needs review to prevent confusion. Generally risks were found to be well managed but assessment of risk was needed for one tenant regarding epilepsy and poor appetite. Further detail was also needed in the manual handling assessment regarding transferring methods to and from a wheelchair. All confidential information pertaining to tenants was seen to be securely stored. Manor Park Grove, 5 DS0000016800.V279567.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): 15, 16, 17 Contact with family and friends is facilitated, both in and out of the Home. Tenants rights are respected. Tenants are offered a healthy diet and enjoy their meals but improved tracking is needed for tenants who are not eating as normal. EVIDENCE: Discussion with staff and tenant records showed that they maintain contact with their family and friends. There was no evidence of strict house rules. Staff were observed sitting and socialising with tenants. Tenants are able to choose whether or not to spend time with others, or to have private time in their own rooms. They are encouraged to be as self managing as possible, such as looking after their own rooms as best they can, and supported to do this appropriately. One tenant was observed to do their own ironing and answer the front door. It is positive that one tenant has the opportunity to answer the home telephone. Sampled menus and discussion with one tenant indicated that a variety of food is offered, including fresh fruit and vegetables. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 12 However the tracking of food eaten for one service user who was unwell and not eating as much as usual required improvement to ensure her general well being. One tenant has diabetes and they showed the inspector their own individual menu, they said that the food at the home was good. Manor Park Grove, 5 DS0000016800.V279567.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, 20 Tenants receive personal support in accordance with their needs and wishes. Tenants are offered regular health checks but arrangements for monitoring weight and epilepsy need improvement. Progress towards completing health action plans is evident. Arrangements for the management of the medication are generally sufficient to protect tenants from harm, only minor improvements are needed. EVIDENCE: Care plans indicated the degree of assistance required for personal care, this varied from very little such as prompting to full personal support. A key working system has also been introduced to ensure tenants receive support in the way they prefer it. It is good practice that a photographic chart of staff enables tenants to be clear about who is their key worker. Sampled records evidence that where tenants are unwell appropriate medical advice is sought. Discussion with the Manager indicate that there have been some difficulties in accessing flu jabs for tenants due to issues of consent. General health checks are also undertaken, one tenant has recently been referred to the epilepsy consultant for a full review of their needs. Information needs to be available in their care plan to guide staff as to the type of epilepsy, likelihood of a seizure occurring and action to taken in the event of a seizure occurring. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 14 Records do not show that tenants weight is being regularly monitored. It is especially important that weight is monitored for service users who have communication difficulties, suffer from lack of appetite or other medical conditions. Weight loss or gain can be an indicator that someone is unwell. Since the last inspection the Manager has introduced a system for health action planning. These plans are currently in various stages of completion. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. The system for the administration of medication is generally satisfactory but some minor improvements are needed. Medicines were seen to be stored appropriately in a secure location. Copies of prescriptions are retained. A recent medication error occurred in the home when a tenant was given the incorrect medication. The action taken so far by the Manager to prevent future occurrences has been appropriate. Discussion with the Manager indicates that not all staff have received accredited medication training. However, medication competence assessments are completed for all staff who administer medication and medication training has been booked for staff who require it. The Manager has completed some medication competence assessments of staff, however the Manager has not completed accredited medication training. Only staff who have completed this training should be assessing staff. The home has been provided with an updated medication policy, however this was observed to contain no guidance for staff regarding controlled medication. One tube of topical ointment had been dated on opening in September 2005. However it had not been disposed of 28 days later, medication audits had not identified this. The Manager needs to ensure creams and ointments are disposed of and medication audits identify where this has not been done. Manor Park Grove, 5 DS0000016800.V279567.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 Tenants know that they can complain and that matters will be dealt with. The arrangements in place to protect tenants from the possible risk of harm or abuse require improvement. EVIDENCE: The CSCI has not received any complaints regarding this home in the last twelve months. The homes own complaints log shows the home has not directly received any complaints. Discussion with one tenant showed that she had a clear understanding of the complaints procedure. It is good practice that tenants have a card located in their bedroom that they can post if they have any complaints. It was identified at the last inspection in August 2005 that staff required training in adult protection, this has not yet been done. The Manager said that this training was planned to take place in February. The home was observed to have a copy of the Birmingham Adult Protection Multi Agency Guidelines. The Manager received a copy of the organisations new physical intervention policy. In general the policy was satisfactory but the guidance gave the impression that the psychologist could provide staff training on physical intervention. This is unlikely to be the case. It was also of concern that some staff had received training on personal safety techniques from an organisation that is not accredited with the British Institute of Learning Disabilities. It was explained by the Manager that the techniques taught on the course were not for use with the tenants. However there is a danger that staff could use these techniques with the tenants and it does not make practical sense to attend a course where what you have learnt is not of benefit for the client group who you are working with. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 16 Discussion with staff and sampling records indicate that there has been no incidents where physical intervention has been necessary. A list of possessions was observed to have been completed in September 2004 for each tenant. However since then the list had not recorded when new items had been purchased and old one discarded. The Inventory needs to be kept to up to date to ensure that tenant’s possessions have not gone missing. The Manager had already recognised this needs and has completed a new format for tracking possessions that he says is soon to be implemented. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The standard of the environment within this home is generally satisfactory and presents as a homely and comfortable environment for the people who live there. EVIDENCE: The home was seen to be well maintained, comfortable, and free from odour. Furniture, fixtures and fittings were of a good standard and well maintained. The home has a bathroom, separate shower room and separate toilet. The bathroom has a high low bath and chair hoist, which is sufficient for the current service user needs. All bathroom/shower/toilets are lockable. The home has a combined lounge/dining area, which is the only shared space available. There is no communal space for service user to receive visitors, take part in activities of have space away from other service users. This is not ideal. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 18 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, 36 Arrangements to ensure that staff receive the appropriate training and support to meet individual tenants needs need to improve. Staff records do not contain all the information as required to show that the right people are working with the tenants. Systems to support the staff are adequate but could be improved upon to ensure inexperienced staff have additional support. EVIDENCE: It was noted that both staff and tenants appear comfortable in each other’s company and enjoy a good general rapport. They give support with warmth, friendliness and patience and treat people respectfully. The home has undergone major changes to its staff team with several staff leaving and many new staff recruited. The current team therefore comprises of quite a high percentage of relatively inexperienced staff. Two staff at the home have completed an NVQ in care. The home therefore does not meet the standard of 50 of staff having an NVQ, however other staff are working towards this. The Manager has recently completed an audit of the staff files to identify any that have missing information. He had received an envelope of copies of missing documents form the personnel department following his audit and these will now be transferred to staff files. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 19 Two staff files sampled contained most of the information required to show that satisfactory recruitment checks are undertaken on new staff. Criminal Record Bureau numbers were available but not the actual disclosure as required. Discussions with the Manager indicate a positive attitude towards training and development of the care team. As many of the staff are new there is quite a lot of training that needs to be organised for them, and also existing staff. Some of the new staff are undertaking the Learning Disability Award (LDAF) training and this will cover some of the mandatory training they need. Evidence was observed that new staff are also undertaking an induction to the home. Training required for some staff includes adult protection, fire, manual handling, epilepsy, diabetes and medication. The previous inspection in August 2005 identified that staff were not receiving regular supervision. Records indicate that in recent months the frequency of supervision has improved and that staff meetings have recommenced. It is recommended that the frequency of staff meetings and supervision for inexperienced staff is increased to ensure the relatively new staff team is working effectively. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 20 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, 40, 42 Adequate arrangements are in place to ensure that tenants benefit from a well run home. Quality assurance systems require development to ensure Tenant’s views underpin all self-monitoring, review and development by the home. Policy and procedures need to be reviewed to ensure they reflect the National Minimum Standards and current good practice. Arrangements are not adequate to ensure that the health, safety and welfare of tenants is promoted and protected. EVIDENCE: The Manager is not yet registered with the CSCI but he is experienced in working with individuals who have a learning disability and has previous management experience. An application for registration has not yet been received as required previously. Direct observations and previous inspection reports indicate that the style of management is open, and both tenants and staff find the Manager to be an approachable person. One member of staff said that the home had become a more organised place since the Manager had started working there. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 21 The Manager said that monthly visits are made to the home by his Manager but that he has not received reports of the last few visits. These need to be available in the home and also copies sent to CSCI. The home does have policy’s and procedures in place for quality assurance but the tools recorded in the policy are not all put into practice. Further work is needed to ensure a working quality assurance system is in place. The Manager said that Quality Assurance is a key theme for development within FCH in 2006. The Manager has completed some internal audits to include contents of staff files and it is good practice that an action plan for the home has been completed. Several policies and procedures were sampled. Many were observed to require review as they were dated prior to the introduction of the National Minimum Standards. For example the policy on the use of agency staff did not indicate the process that needs to be undertaken to ensure the staff have a suitable Criminal Records Bureau check. A number of health and safety documents were sampled. An examination of the home’s fire safety records indicate that routine testing of alarms is being carried out at the appropriate frequencies. Emergency lighting is being tested three monthly rather than the required monthly test. However the lights had been serviced in January. Certificates were available to evidence the regular servicing of the Arjo bath, fire alarms, gas and electrical appliances. It is required that staff receive fire training at least six monthly to ensure they are aware of fire prevention and respond appropriately in the event of a fire occurring. This is an outstanding requirement from the previous inspection. Staff test the water temperatures weekly and keep a record of these. These showed that most of the temperatures are below the safe recommended temperature of 43 degrees centigrade. Temperatures of the fridge and freezer are monitored daily. Recently the fridge temperatures are quite high, discussion with the Manager indicates that staff feel it is the thermometer that is inaccurate and not a problem with the fridge. The Manager said a new thermometer is being obtained. Risk assessments for the premises were observed to be well overdue for review. Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 22 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 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 2 X 2 X Manor Park Grove, 5 DS0000016800.V279567.R01.S.doc Version 5.1 Page 23 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 17(2) 4(1)a Sch4(1) 14 Requirement The statement of purpose must be finalised and made available to service users. Outstanding requirement from 30/3/05. Care plans require further improvement to ensure: They are reviewed at least six monthly. Outstanding from 30/10/05. Specific support needs are included, for example epilepsy the type of epilepsy, signs of being unwell and the action staff need to take in the event of the service user being unwell. Risk assessments must be available for all areas of identified risk to include epilepsy and poor appetite. Records of food provided to tenants must be maintained in satisfactory detail to evidence a balanced diet is being offered / eaten. All tenants must be offered the opportunity to be weighed monthly and a record of this kept All staff that handle medication must have accredited training. DS0000016800.V279567.R01.S.doc Timescale for action 30/03/06 2. YA6 28/02/06 3. YA6YA19 12(1) 14 20/02/06 4. YA9 12(1) 13(4) 12(1) 16(2)(i) 28/02/06 5. YA17YA19 28/02/06 6. 7. YA19 YA20 12(1)(a) 13(2) 18(1)(a,c) 28/02/06 30/03/06 Manor Park Grove, 5 Version 5.1 Page 24 8. 9. 10. YA20 YA23 YA23YA34 13(2) 12(1) 13(4) 13(4) 19 18(1)(c) 13(6) 11. YA23YA35 12. 13. YA37 YA39 10 12(1) 14 14. YA39 26 15. YA2YA40 12(1) 14 16. 17. YA42 YA35YA42 13(4) 23(4) 18(1)(c) 23(4) Managers who complete medication competence assessments must have completed accredited training. Topical creams and ointments must be discarded 28 days after opening. Inventories of tenants possessions must be kept up to date. Evidence of CRB checks must be available in the home for all staff. Disclosure must be available on site for 12 months. Ensure staff have received all the training they need to meet tenant needs to include: Adult Protection Manual Handling Epilepsy Diabetes Scheduled training dates to be sent to CSCI. An application must be made to the CSCI to register the manager. A formal quality assurance system must be in place that seeks the views of tenants and their representatives. Reports of the monthly visits made to the home by the representative of FCH must be available and also sent to CSCI. Policies and procedures must be subject to regular review to ensure they reflect the National Minimum Standards, any changes in legislation and current good practice. To include the admission and assessment policy as previously required. The emergency lighting must be tested monthly with a record maintained. Ensure staff have received fire training six monthly. Outstanding from 23/9/05. DS0000016800.V279567.R01.S.doc 28/02/06 28/02/06 28/02/06 28/02/06 28/02/06 30/04/06 28/02/06 30/04/06 28/02/06 01/03/06 Manor Park Grove, 5 Version 5.1 Page 25 18. YA42 13(4) Risk assessments for the premises must be reviewed annually. 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA9 YA23 YA28 Good Practice Recommendations The current system of having two risk assessments (one a copy of the original) is confusing. It is recommended that the organisation of risk assessments is reviewed. The training of staff in protection teqniques should be reviewed as it is not BILD accredited. Communal Space:The home has a combined lounge and dining area. There is no alternative communal space for tenants to receive visitors or take part in activities or have space away from the other service users. Consideration should be given to the provision of extra space, for example a conservatory. Brought forward from previous inspection. It is recommended that the frequency of staff meetings and supervision for inexperienced staff is increased to ensure the relatively new staff team is working effectively. 4. YA36 Manor Park Grove, 5 DS0000016800.V279567.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 Manor Park Grove, 5 DS0000016800.V279567.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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