Inspection on 23/08/05 for Manor Park Grove, 5

This inspection was carried out on 23rd August 2005.

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 but made no statutory requirements on the home.

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 20/01/06

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 5 Manor Park Grove Norfield Birmingham B31 5ER Lead Inspector Kerry Coulter Unannounced 23 August 2005 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 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 Stationary 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 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Manor Park Grove, 5 Address 5 Manor Park Grove Norfield Birmingham B31 5ER 0121 476 5821 Telephone number Fax number Email 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 Vacant Care Home 4 Category(ies) of Younger people with learning disabilities. registration, with number of places Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 22 January 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 service user has a single bedroom, which have been furnished and decorated to the individual taste with assistance from service users. Each bedroom has a wash hand basin. There is a communal bathroom with an Aquonova 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 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted by one inspector. The inspector spoke with all service users. Time was also spent observing care practices, interactions and support from staff. A tour of parts of the building and garden was made. Service user care plans and risk assessments were inspected. Staff training and recruitment procedures were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk with the Manager, Team Leader and several members of staff. During this visit the inspector did not have opportunity to speak with relatives and other professionals. What the service does well: What has improved since the last inspection? The service user guide has been further developed and is now in a style that is more accessible to service users. The washing machine has been replaced with a sluice cycle machine in order to effectively manage soiled linen. Staff vacancies have been recruited to and staffing levels are now satisfactory. A new manager has commenced work in the home and demonstrated an understanding of areas the home needed to improve. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 6 The Manager has recently introduced a staff rota that is in a format suitable to the needs of service users. 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 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 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 standard(s) 1 and 2 The Statement of Purpose does not provide clear information for prospective service users to be clear about the services the home provides to meet their needs. EVIDENCE: The service user guide has been further developed since the last inspection. The document is now in a style that is more accessible to service users and includes pictures. It is also available to service users on tape if required. The statement of purpose for the home is still in draft form and the document contains several gaps where the detail still needs to be added. It has been required at several inspections that this document is finalised. It was previously required that the home has an admission policy and procedure. A policy was available at this inspection, however it was dated 1995. This document will require 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. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 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 standard(s) 6, 7 and 9 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 on how this information links in with the care plans. Staff support service users to make choices and decisions about day-today things in their lives. EVIDENCE: Observation of care practice and sampling of records clearly indicated that service users are enabled to make decisions about their own lives. The ethos of the home is service user focused. One service user spoken with confirmed she was involved in making decisions, this includes menu planning, holiday destinations and choice of activity. The Manager stated that he intends to develop systems for service user involvement in staff recruitment. The home does not hold tenant meetings but one tenant represents the others at meetings held by the organisation, each home has the opportunity for a service user to attend. The Deputy Manager was not aware of any minutes of these meetings, it is recommended that these are made available to service users who do not have the opportunity to attend. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 10 Two service user 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 needed to be added to the care plan of one service user regarding diabetes, to include the type of diabetes, signs of being unwell and the action staff need to take in the event of the service user being unwell. The tenant profile of one individual was in the process of being updated but the other had not been reviewed since September 2004. The care plans need to be reviewed at least six monthly. One care plan did contain evidence of service user involvement but consideration needs to be given to increased service user involvement in the care planning process to include some goal setting within the plan. Risks had been identified, assessed and regularly reviewed. Generally risks were found to be well managed. However further work needs to be done to ensure service user risk assessments directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other. One of the outcomes for completing risk assessments and care plans should be that the finished article is a simple and effective working document, in which essential information can be easily found. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 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 standard(s) 12 and 13 A range of activities is offered in order to promote personal development, participation in the life of the local community and enjoyable leisure time. EVIDENCE: Service users participate in a good variety of daytime occupations including college, structured day centres and a wide range of community based activities, facilitated by staff. There is evidence that all service users have an opportunity for 1:1 support, as well as going out in small groups. Service users are enabled to take part in a wide variety of community based activities including bowling, cinema, church, meals out, classes, pub, shopping. One service user who spoke with the inspector was satisfied with the range of opportunities on offer. On the day of the inspection all service users participated in community activities. Informed choice about what activities are on offer is given by staff. A member of staff was heard telling one service user about a forthcoming gardening show, when and where it was as well as what entertainment would be on offer. The service user was then given time to think about whether she wanted to go. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 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 standard(s) 19 and 20 The health needs of service users are generally met. The systems for the administration of medication are generally good with clear and comprehensive arrangements being in place to ensure service users receive the medication they need. EVIDENCE: A sample inspection of service users’ health records indicates that service users are receiving routine access to general health services, such as well person’s checks, dentist, eye tests, flu vaccinations and chiropodist. One service user is currently receiving input from health professionals to include the Speech and Language Therapist. The home needs to consider how health action plans for service users can be introduced. 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. It may be that this is an opportune time to engage with the local Community Nurse (Learning Disability) Service in order to move this forward. The system for the administration of medication is satisfactory. Medicines were seen to be stored appropriately in a secure location. A random audit of stocks held revealed no discrepancies, and there were no gaps on the administration record. Discussion with the Manager indicates that not all staff have received Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 13 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. Detailed protocols on the use of ‘as required’ medication had been completed. Where appropriate, protocols had been written in consultation with other health professionals. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 14 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 standard(s) 23 The lack of adult protection training and Criminal Record Bureau information for some staff impact on the homes ability to show that service users are being protected from abuse and that their welfare is being promoted. EVIDENCE: The home was observed to have a new adult protection policy, this was satisfactory. Staff had also signed a record sheet to evidence they had read the new policy. The home also has a copy of the Birmingham Adult Protection Multi Agency Guidelines. However, staff training records did not evidence that all staff had received prevention of abuse and adult protection training. It is evident that this is required as several days after this inspection an incident occurred with a member of the public that had the potential to cause distress and possible risk to both a member of staff and a service user. Unfortunately there was a delay in reporting this incident to the Deputy Manager and consequently there was a delay in notifying the police. Evidence of Criminal Record Bureau (CRB) checks was not available for all staff, however the Manager stated that no staff are employed without a CRB and evidence is available at the organisation’s headquarters. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 15 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 standard(s) 24, 26, 27, 28 and 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: A service user gave the inspector a tour of the home. The home is an attractive and well maintained home, providing accommodation on a domestic scale in a comfortable modern environment. One service user bedroom was sampled. It was observed to be personalised with plenty of evidence of personal effects and possessions. People can do their own thing, watching television or listening to music, and so on, whenever they wish. One service user spoken with said they were happy with their bedroom and had everything they needed but did not want the inspector to observe their room. Communal areas were observed to be generally well decorated and equipped with modern furnishings of a satisfactory quality. 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. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 16 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. The home has a separate laundry, which is sited off the main hallway. As required at the last inspection the washing machine has been replaced with a sluice cycle machine in order to effectively manage soiled linen. The home has an infection control policy in place. Liquid soap and hand towels are provided in the laundry, kitchen and bathrooms/shower rooms and WC to prevent the risk of cross infection. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 Current staffing levels meet the needs of the service users. There is a continuous training programme in place for staff, and this should be developed further in accordance with service users’ assessed needs. Staff records require improvement to evidence that service users are being safeguarded by satisfactory recruitment procedures. EVIDENCE: It was noted that both staff and service users 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. Major shortfalls were identified regarding staffing at the last inspection in January 2005. The home had many staff vacancies and due to the majority of staff rotas being unavailable for inspection it was not possible to determine if adequate staffing levels were being maintained. Staffing levels were appropriate to the needs of service users at the time of this inspection. All the rotas were available. Observation of these documents and discussion with staff indicates that staffing is an area of improvement. Staff vacancies have been appointed to and a new Manager has commenced work. Rotas indicate that the home does not use agency staff, any deficits are Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 18 covered by casual staff or permanent staff working extra hours. Discussion with the Manager indicates that the home has had some difficulties with high levels of staff sickness. However, appropriate action is being taken to manage this, including returning to work interviews with staff. The Manager has recently introduced a staff rota that is in a format suitable to the needs of service users. It is in a photographic format and is on display in the hallway. One service user spoken with said that she liked the new rota as it enabled her to see who was going to be on duty. The home has not had a staff meeting since March 2005. The Manager said it had been difficult to arrange a meeting as the venue they had used was now unavailable. The Manager needs to find a new venue or possibly hold a meeting in the home when service users are out on activities. Discussion with the Deputy Manager and observation of the supervision matrix indicates that staff have not received formal supervision on a regular basis. The Deputy stated in the absence of the home having a Manager in post it had proved difficult to conduct regular supervision. Now that the new Manager is in post it is anticipated that the frequency of supervision will improve. Newly recruited staff undertake an induction to the home. A four week induction time-table was observed for one recently recruited member of staff. The recruitment records for this member of staff were sampled. These included an application form, proof of identity and two written references. Confirmation was available from the personnel department that a Criminal Records Bureau check had been undertaken, but a copy of the disclosure was not available for inspection. Additionally, the Manager and Deputy Manager were unable to find CRB information for several members of staff. They will need to complete a full audit of staff files to ensure they contain the required information. From the available staff records it was difficult to assess if all staff have received the training they need to meet the needs of service users. It was unclear if records had been kept up to date, the records available would indicate that several staff require refresher training in areas such as fire, adult protection, manual handling, epilepsy and diabetes. The Manager needs to audit the training needs of the staff group, it is suggested that a training matrix is completed. Discussion with the Manager indicates that the organisation has recently appointed a second training co-ordinator and outstanding training will soon be offered to staff. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 42 The arrangements for staff training do not adequately promote and protect the health, safety and welfare of the service user. EVIDENCE: The home has been without a registered manager for some months. A new manager has now commenced work in the home. Discussions indicate that he is experienced in working with individuals who have a learning disability and has previous management experience. The manager was aware and had an understanding of areas the home needed to improve. An application for registration must be made to CSCI. A number of health and safety documents were sampled. An examination of the home’s fire safety records indicate that routine testing of alarms and lights is being carried out at the appropriate frequencies. The records also show that fire drills are being routinely carried out. Certificates were available to evidence the regular servicing of the emergency lights, Arjo bath, gas and electrical appliances. The most recent available servicing certificate for the fire alarms was dated 13th July 2004. An immediate requirement was made for the alarms Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 20 to be serviced and a copy of the certificate forwarded to the CSCI. This was received after the inspection and recorded the alarms had been serviced in July 2005. One staff file recorded that the individual had not had fire training since 2003. 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. However a training document indicated that the organisation offers fire training every two years, this will need review. It was observed that the homes folders containing health and safety information and certificates were quite disorganised. It is recommended that these are re-organised with any old certificates archived. This will enable staff to speedily locate any required information. The COSHH cupboard was checked and found to be secure. The hot water monitoring log confirmed that water temperatures are checked weekly and a hand test carried out at this inspection confirmed that water was of a comfortable and safe temperature. Accident records recorded that an accident had occurred when a reserve member of staff had assisted a service user to transfer from a wheelchair to chair. It was queried if this reserve member of staff had received manual handling training. The Deputy Manager stated that following this accident the reserve staff had been nominated for training. The Manager will need to ensure that all staff who are assisting service users to transfer have received manual handling training to reduce the risk of accidents. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 21 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 2 2 x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 2 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x x x Standard No 31 32 33 34 35 36 Score x x 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Manor Park Grove, 5 Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 17(2), 4(1) a, Schedule 4(1) 14 Requirement The statement of purpose must be finalised and made available to service users. Outstanding requirement from 30/3/05. The admission policy and procedure requires review to ensure it reflects the National Minimum Standards. An admission criteria must be available for the home. Care plans require further improvement to ensure: 1. They are reviewed at least six monthly. 2. Specific support needs are included, for example diabetes the type of diabetes, signs of being unwell and the action staff need to take in the event of the service user being unwell. 3. Consideration needs to be given to increased service user involvement in the care planning process to include some goal setting within the plan. Service user risk assessments need to directly cross-reference to the element(s) of the care plan to which it relates, and vice versa, so that the reader is Timescale for action 30/10/05 2. 2 30/11/05 3. 6 15 1 & 330/10/05 2- 7/9/05 4. 9 13(4) 30/10/05 Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 23 5. 6. 19 23 12(1) 13(4)(6) & 37 7. 8. 9. 23 & 35 23 & 34 33 18(1)(c ) & 13(6) 7, 9, 19, Schedule 2 18(2) 10. 35 & 42 13(4) 18(1)(c ) and 23 11. 12. 36 37 18(2) 10 naturally directed from one to the other. The home needs to consider how health action plans for service users can be introduced. Incidents that have the potential to put service users at risk of harm or abuse must be reported to a manager from FCH, Social care and health/CSCI/ Police as appropriate without delay under adult protection procedures. Ensure all staff have received training in adult protection. Evidence of CRB checks must be available in the home for all staff. Resolve the problem of a lack of venue for staff meetings and ensure staff meetings occur on a regular basis, a minimum of six per year. 1. Complete an audit of the training required for the staff team and provide the CSCI of planned training schedule to include manual handling training. 2. Ensure staff have received fire training six monthly. Ensure staff receive formal supervision at least six times per year. An application must be made to the CSCI to register the manager. 30/10/05 Within 24 hous of occurance 30/11/05 10/10/05 30/10/05 and ongoing 23/9/05 30/9/05 and ongoing 30/10/05 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. Refer to Standard 7 Good Practice Recommendations It is recommended that Manor Park Grove is provided with the minutes of the tenants meetings held external to the home. E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 24 Manor Park Grove, 5 2. 28 Communal Space:The home has a combined lounge and dining area. There is no alternative communal space for service users 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. 3. Manor Park Grove, 5 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Birmingham and Solihull Local 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 E54 S16800 Manor Park Grove 5 V246417 240805 stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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