Inspection on 22/08/05 for Mary Street

This inspection was carried out on 22nd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mary Street 10/08/06

Mary Street 16/01/06

Mary Street 10/02/05

Mary Street 05/08/04

Mary Street 21/01/04

Mary Street 19/08/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mary Street 179 Mary Street Balsall Heath Birmingham B12 9RJ Lead Inspector Monica Heaselgrave Announced 22 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 Older People. 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. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mary Street Address 179 Mary Street Balsall Heath Birmingham B12 9RJ 0121 446 5719 0121 446 5719 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 Mrs Valerie Paragon Care Home 21 Category(ies) of Old Age (20) - Physical Disability (1) registration, with number of places Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 21 service users requiring care by reason of old age (over 65). 2. This number may include the one existing service user as at 2003, who requires care by reason of physical disability. Date of last inspection 10 February 2005 Brief Description of the Service: FCH Housing and Care own and manage 179 Mary St, which is registered to provide care and support to 20 older people and one younger adult with a physical disability. It currently offers this service to people from the AfroCaribbean community. The home is situated in a residential area and is close to local shops, pubs, medical centre and places of worship. It is well served by public transport. Facilities briefly include 21 individual flats, each with its own lounge, bedroom, bathroom and kitchen. Each flat has a buzzer facility to summon staff for assistance. Each service user has their own lockable front door. Service users can decorate and furnish their flats to individual taste. FCH Housing and Care are responsible to the maintenance and repair of the flats and the rest of the building which consists of a communal lounge, dining room, office staff rooms and laundry. The grounds are also maintained by FCH Housing and Care. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place between 10:00 hours and 16:30 hours on a Monday. The inspector met with the Registered Manager, the Care Business Manager, Assistant Manager, and one care staff for formal discussions. An agency staff member and two care staff members were observed in their care practice. Eleven service users were consulted during the course of the inspection. Observations were made of other service users to include the lunchtime meal. A number of records were inspected which include, care plans, risk assessments, daily records, staff records complaints, accident and incident records. Certificates for the maintenance of fire equipment, gas, electric and mechanical hoists were also inspected. The inspector had the pleasure of speaking with five service users in their flats, during which a tour of their flat was undertaken. What the service does well: Mary Street has a consistently good record of maintaining personalised services to its service users. Staff provide a service to older people from the Afro-Caribbean culture. They achieve this well, as comments from service users and staff confirmed. Consultation with service users is positive, they are actively encouraged to contribute to the way in which they want their care delivered. This has ensured a good degree of flexibility, so that the service user is provided with a care plan that meets with their expectations and preferences. People living at Mary Street enjoy good standards of care, which encourages a high level of choice and independence in some aspects of their life. The building is conducive to this, as it offers each service user his/her own self-contained flat, in which some continue to undertake everyday activities with support. Once service user stated I enjoy having my own space, I can shut the door, but have help when I need it . There are very good systems in place for monitoring and reviewing care practices and care plans. There is a well established system which is highly effective in determining, with the service users, their preferred daily routines, likes and dislikes and the level of assistance they require. The quality of food, Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 6 as described by service users is very good. Once service user stated, Food tastes different to everyone, I like them (staff) to cook it my way. A great deal of consideration has been given to the provision of meals, both from a health and cultural point of view, in order to provide authentic and nutritional dishes. All the service users who contributed to the inspection process, spoke highly of the manager and her care staff team. They describe them as caring and hard-working. Mary Street provides a caring and supportive residential experience within which routines are relaxed, and staff were observed to be tactile, friendly and encouraging in their interactions with service users. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 Information about the home is clear and concise and helps service users choose a home that is culturally right for them. There is an excellent, comprehensive assessment of needs followed up with comprehensive care plans and agreements between the home and service users, as to the care they wish to receive. EVIDENCE: There is a range of information available to service users, to include Statement of Purpose and Service User Guide, which provides detailed and specific aims that staff intend to offer. There are specific aims for people from the AfricanCaribbean culture. A copy of these was provided and seen to have been amended since the last inspection. These now meet the standard in full. The Service User Guide also provides feedback from the quality assurance program which seeks the views of current service users. There is a contract between the provider and service user which specifies the relationship between the two. Service users were well informed of what they could expect in terms of accommodation, care support, their rights and the fees payable. There is a full and comprehensive assessment for each service user moving into the home. 11 of these were seen. The assessment included perspective Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 9 service users meetings with staff members, including the cook to identify their specific needs, likes and dislikes. The assessment forms and individual care plans are available in each flat. These were seen to provide an excellent working tool for staff. Staff members sign a record at each shift, for care that has been delivered. These are kept in each flat, so the service users have full access to any information recorded about them. 11 service users were spoken to and said that the staff members are all very responsive. When they visit their flat, they know what help to provide, and what to leave for the individual to do so themselves. The cultural needs and preferences of individuals are exceptionally well documented. Specialist health care needs such as sickle cell anaemia, are well documented and reflect relevant specialist and clinical guidance that has been sought in order to provide for the individual needs. Staff training records were sampled to demonstrate that they have the individual and collective skills to deliver the care that is offered. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10, 11 The personal care needs of service users are met by skilled, caring and trained staff, who consistently strive to make sure service users are comfortable. There are excellent examples of promoting and protecting individuality, independence and autonomy for service users. EVIDENCE: Care plans are exceptionally well detailed, and include a wealth of information as to how the health, personal care and social care needs of the service users are met. There are good examples of supporting individuals capacity for selfcare. Risk assessments, particularly in the risk of falls, are evident and well detailed. Service users stated that they have regular meetings with their key worker, which are recorded, and used to change their care plan or routine as needed. Service users feel they are fully consulted about the level of care they need, one gentleman stated, I like support with cleaning my flat. They manage my medication, and shopping but I look after my own money. I decide when I get up, what I eat, and whether I eat in my flat or in the dining room. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 11 Another stated, I like a cup of tea about 7 a.m., but stay in bed till 10. I need a lot of help with my personal care and see my physiotherapist regularly. I like my nightly checks to see if Im comfortable. Staff are very good to me. Several service users stated that the staff are responsive to their buzzer in the flat, but at times staff are stretched and many have to be called away. One service user said I know they are busy, and trying to help others so I try to be patient, they do always come back. Staff spoken to had a very good understanding of the needs of the people they were caring for, and supporting. They recognise that some service users’ needs have changed, and require a higher level of physical care. This impacts on the amount of time they can spend with individuals doing other things. This was discussed, with the Manager and Care Business Manager. It was agreed that where the needs of individuals have changed significantly, that a review of staffing levels is undertaken, and that where appropriate, a referral for nursing care is made. Health care needs are particularly well promoted. The management of continents, pressure sore care and psychological well-being, is well documented, and include specialist support services. Care plans showed that continence advisers, district nurses and mental health consultants are actively involved in the plan of care. Service users felt that they are treated with respect. Staff were observed referring to individuals in their first name, or family name. One gentleman stated we come from different parts, different islands, and we like our food to taste that way, thats respect. Service users have their own self-contained flats and can determine their routines, and where their care is delivered. All felt that this respected their privacy. Staff have access to policy and procedures relating to dining and death. They have experienced this event. Care files show that each service user has a last wishes document, signed and dated by them. This gives detailed information regarding their preferences in the event of death. This demonstrates nicely, that service users have been given the opportunity to discuss this eventuality and have their wishes respected. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 There is a range of creative ways in which service users are assisted to manage their lives, maximising their capacity to retain personal autonomy and choice. Meals are wholesome, appealing and culturally authentic. EVIDENCE: The building in which service users live is very conducive to maximising choice and control over ones life. Each flat has its own lockable front door, a single bedroom, lounge kitchen and bathroom. All flats have emergency call facilities to summon staff. Service users spoken to, stated they welcomed their facilities, because it gives them choice to live fairly independently. On the day of inspection it was observed that some individuals spent a large amount of their time in their own flats as opposed to the communal facilities. Service users describe their daily routines which are managed in a way that allows great flexibility. Service users are not restricted by set routines or communal living arrangements. Care plans viewed, clearly reflect that a great deal of consideration is given to ensuring the care provided, is based upon the expectations and preferences of the individual. This is supported by extremely well-documented lifestyle choices. Service users were seen to have a list of appropriate and chosen activities which is updated via their meetings with their key worker. These included going to the cinema, meals out, attending dances, clubs, college clubs or Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 13 places of worship. Some detail support to go to local polling stations or maintain existing links within their community. Service users also had the opportunity to engage in activities within the home, which included card games, Dominos, bingo, table tennis, singing and praying. A yearly theatre group takes place, and a fortnightly religious service in the home. Some service users continue to cook and shop, or undertake light domestic tasks in their flats. Risk assessment seen detail the risk posed to individuals, and how these were to be minimised. This enables individuals to continue to enjoy activities, in a safe and supportive environment. Service users confirmed that they could receive visitors in the privacy of their own flats. Contact arrangements are specified on each service users’ care plan, this ensures that family and friendship links are maintained. Some service users confirmed that they receive their mail, and manage their personal and financial affairs independently. All service users have access to their care plan and daily records. These are maintained by them in their own flats. Service users were particularly positive in their comments concerning meals. It was evident that a great care has been given in relation to supporting service users to decide for themselves what they eat, when they eat and where they eat. Some service users stated, “I like to do my own breakfast and eat in my flat, but have my dinner with the others in the dining room. One gentleman stated, food tastes different to everyone, I like them to cook it my way. It was admirable to see that great care is taken when considering the nutritional needs of service users both from a health and cultural point of view. Likes and dislikes lists are drawn up with the service users and cook and identifies how the food is to be prepared. Some service users prefer more seasoning or herbs, all the dishes cooked differently depending on whether someone originates from Trinidad, Tobago, Barbados, Sierra Leone or Africa. Specialist therapeutic diets are evident for those who need to maintain nutrition or appetite. This included one for someone who suffers with anorexia. Diet plans also, where necessary to specify the specific support required. This included eating meals in the communal area so that fluid and food intake can be monitored, for those at risk of weight loss or gain. One service user has a risk of choking. A risk assessment was seen but this was not evident in the kitchen, dining area to alert all staff. Given that the agency staff have worked in the home, this risk assessment needs to be displayed in the kitchen area where it can be clearly seen by staff, but not on public display. Menus viewed were varied, balanced and provided wholesome and interesting meals. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 Complaints are handled properly and provide service users with confidence that their concerns are listened to and acted upon. The provision of adult protection procedures and training given to staff, ensures people living at the home are protected from abuse. EVIDENCE: There is a complaints procedure, and service users have access to this in their own flat. Service users spoken to indicated that they know how to make a complaint, but had not needed to. They were confident that staff would listen to them. No complaints have been received by the CSCI. The manager needs to introduce the log which will help separate the complaint information from other statistical information. Service users are enabled to access advocacy services, and some have identified family members on file who undertake this role. Staff ensure service users have the opportunity to vote in elections, and provide support to access polling stations, this is specified in their care plan. Care staff have access to the organisations adult protection procedures. Staff training records indicate that staff receive training in relation to protection and abuse. A staff member spoken to had a good knowledge of the indicators of abuse, and how they should act on this. Incident records showed there had been one incident of aggression to a member of the staff. The risk assessment is available on this persons file, to show how this behaviour is to be managed. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 26 Service users needs are met, individually and collectively in a safe, comfortable and homely environment. The provider has addressed previous environmental requirements to ensure service users continue to live in a well maintained home, conducive to their needs. EVIDENCE: The inspector visited five flats, and spoke to their occupants. Each was pleased with the maintenance arrangements carried out by the maintenance operative. One gentleman said my door handle fell off and he came to fix it straight away. The flats were seen to be clean, well furnished and comfortable. Some service users informed the inspector that they undertake light domestic tasks in their flat which they enjoyed. Domestic support is available and all communal areas were clean and odour free. Although the maintenance operative was not available to this inspection, the inspector was satisfied from records viewed, that repairs and a general redecoration programme is followed. Since the last inspection all communal areas have been redecorated and handrails painted in contrast in colours to enable service users to see them more clearly. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 16 The home is fully wheelchair accessible, and a shaft lift provides access to the first floor. Communal areas and corridors are spacious and provide sufficiently for manoeuvrability of wheelchairs. Each flat has its own toilet and bathroom. These are equipped to meet the needs of the service users. Additional facilities are provided near to communal areas. There is a variety of aids such as hoists, and assisted toilets and baths. Grab rails are suitably positioned to assist maximum independence. Service users have stated that the equipment they require is provided, following consultation with themselves and an occupational therapist. Service users can furnish their flats with their own belongings. Inventories of these are maintained and were seen. Each flat viewed was individual in its appearance and well furnished, all were comfortable and clean. The home has lovely outdoor areas. Service users are assisted to grow a variety of vegetables and herbs. Many stated they enjoy the garden area. Staff training record shows that they have received training in relation to hygiene and infection control, manual handling, health and safety, fire safety, continence management and pressure sore care. This ensures that the equipment, facilities and care provided within the home meets the assessed needs of the service users, and ensures a safe environment for them. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 The current recruitment procedures provide adequate safeguards the service users living in the home. EVIDENCE: Following a previous inspection, the CSCI received an action plan indicating that no new staff would commence working without a POVA 1st check and two references. Three staff files were sampled and all had two references and a current CRB check. The Pre inspection questionnaire completed by the registered manager shows all staff currently employed to work in the home had a CRB check. Two care staff are awaiting their CRB checks to be returned to the home, these were applied for in May and June 05. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36 The home is managed well, with the interests of service users being the central focus. This results in high standards which promote the health, safety and well-being of service users. EVIDENCE: The manager is experienced, competence and up-to-date with her training needs. She is qualified to NVQ level 4 in care and hold the registered managers award as well as the assessors award D38 and D33. Service users and staff spoke positively about the ethos of the home. There are good examples of written communication, to ensure consistency of care. Staff had a good knowledge of service users’ needs and how these should be met. There is consistency between staff shifts. Service users confirm that staff know their needs and routines and are responsive to them. There are excellent strategies to enable service users and staff to affect the way the care is delivered. These included comprehensive preadmission Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 19 assessments, well detailed care plans and regular key worker and service user consultations, such as service users meetings. The inspector was particularly pleased to see the innovative use of likes and dislike lists- and last wishes lists, these ensure service users have a real voice about their life and demonstrate clearly how the staff team will deliver this aspect of the service. The managers implemented a quality assurance system, based upon seeking the views of service users and their families. The results of these are made available to service users, and extracts are included in the Service User Guide. These enable prospective service users to have a feel of how the home operates and are good examples of being open and inclusive with existing and prospective service users and their families. Two staff spoken to confirm that they have regular monthly supervision sessions, and their staff records verified this. Staff felt that their supervision offered them the opportunity to consider all aspects of their care practice and explored their career development needs. Staff claimed that supervision is utilised to ensure policies and procedures that affect their practice, are known and understood. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 3 3 3 x x 3 x x Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 21 No 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 7 Regulation 14 (2)(a&b) Requirement The Registered Person must ensure that an assessment of an individual is undertaken with a view to a referral for nursing care. The Registered Person must ensure that the risk assessment for choking is alerted to all care staff including agency staff. The Registered Person must ensure that staffing levels are kept under review particularly given the change of dependency levels of service users. Timescale for action 14/11/05 2. 15 13 (4) (c) 22/08/05 3. 33 18(1) (8) 14/11/05 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 16 Good Practice Recommendations The Registered Person should implement a complaints log book in which complaints are recorded, separate from the current statistical information available in the home. Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Birmingham & 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 Mary Street E54 S17013 Mary Street V240047 220805 Stage 4.doc Version 1.40 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!