Inspection on 24/03/04 for Mercian House

Care Homes For Adults (18 – 65)Bamville Road (1)Ward End Birmingham West Midlands B8 2TJUnannounced Inspection24th March 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Bamville Road (1) Address 1 Bamville Road, Ward End, Birmingham, West Midlands, B8 2TJ Email Address Tel No: 0121 326 0491 & 0121 688 5797 Fax No: 688 5797Name of registered provider(s)/Company (if applicable) Mrs Janice Hutton Mr Festus Hutton Name of registered manager (if applicable) Mrs Janice Hutton Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability over 65 years of age (3) Registration number E060000040 Date First registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 7/10/03 If Yes Refer to Part CBamville Road (1)Page 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 324th March 2004 10:00 am Julie Preston Sean DevineID Code074677 153005Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Janice Hutton the time of inspectionBamville Road (1)Page 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. National Minimum Standards for Care Homes for Adults (18 – 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessor’s summary (where applicable) Provider’s Response Provider’s comments Action Plan Provider’s agreementBamville Road (1)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the NCSC in respect of Bamville Road (1). The inspection findings relate to the National Minimum Standards (NMS) for Care Home published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Report of the Lay Assessor (where relevant) • Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Bamville Road (1)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Bamville Road is a 100 year old, domestic style end of terrace property situated in a residential area and in close proximity to a school within the Ward End vicinity of Birmingham. The home offers accommodation to three people with learning difficulties who have lived at the home for a significant number of years. The facilities include lounge, dining room, kitchen, laundry, rear garden, one ground floor and two first floor bedrooms and a small office. The bedrooms vary in size and one was noted to be quite small. The registered manager has arranged a sheltered area with seating within the rear garden for the service user who smokes; the facility permits staff observation from the kitchen window. There is no off road parking facilities. The first floor of the home was extended approximately 5 years ago with a view to increasing the accommodation to six service users; to date this has not been progressed although an application was submitted two years ago as it does not meet the existing standard and the application is unresolved. The home is well situated for local amenities, being close to bus and train routes and Ward End shopping facilities. Care is offered with normal lifestyle principals and service users are allowed to go out unaccompanied.Bamville Road (1)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspector’s Summary (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The inspection took place over one day. It was found that many of the National Minimum Standards had not been met in full and that there were major and minor shortfalls in relation to meeting the Assessed needs of Service Users, Staffing and Conduct & Management of the Home. Choice of Home (Standards 1 – 5) Two of the Five standards were assessed. One standard was met in full and one had minor shortfalls, the home must complete Risk Assessments and Care Plans for service users with epilepsy, diabetes and mobility needs. The home must use assessment tools appropriate for Service Users with a Learning Disability. Individual Needs and Choices (Standards 6 – 10) Three of the Five standards were assessed. One standard had minor shortfalls. Care Plans were in place but needed further development. Care Plans need to include evidence of consultation with service users, actions for staff and service users to take to meet assessed need and assessments for how independent lifestyles can be encouraged. Two standards had major shortfalls and the home must develop a Statement of Purpose and provide service users with information of services available or provided by the home. The home had basic activity programmes for all service users, the home must remove the details of other service users activity programmes from the files of individual service users. Lifestyle (Standards 11 – 17) Three of the seven standards were assessed. Two of the standards had minor shortfalls and the home needs to further develop Individual Activity Programmes for service users based on a thorough assessment, recording the intended outcomes and then review the programmes with service users. Service Users in conversation with inspectors gave positive remarks of their daily activities and were happy with them. One standard had major shortfalls as the home has not developed a Statement of Purpose or gathered information of the Service Users Likes and Dislikes. Personal and Healthcare Support (Standards 18 – 21) Three of the four standards were assessed, two were found to have minor shortfalls, the home has care plans and recorded contacts with GP and other care professionals. The care plans must include an appropriate assessment for service users with learning disabilities, have actions for staff and service users to take with regard to specific health needs such as epilepsy and complete Risk Assessments for service users. The management of medication was of a good standard. However the home needs to ensure relevant staff receive accredited training and also produce Risk Assessments for all service users who selfadminister medicines. One standard had major shortfalls the staff must address their role in sensitively supporting service users taking ownership for making decisions that affect the Health & Safety of other Service Users. Concerns, Complaints and Protection (Standards 22 – 23) Bamville Road (1) Page 6 Both standards were assessed, one was found to have minor shortfalls, although the home has a Complaints Procedure and Log, a Statement of Purpose has not been developed by the home and how service users have been informed of the arrangements in place to make complaints is not recorded. One standard was found to have major shortfalls as the homes Adult Protection Procedure does not comply with the Department of Health’s policy paper “No Secrets” or Birmingham City Council Multi Agency Guidelines. Environment (standards 24 – 30) Three of the Seven standards were assessed. Two of the three were met in full, the home is well maintained, clean and hygienic. Minor special adaptations have been made to the home to assist a service user with mobility needs. One standard was found to have minor shortfalls although the laundry was clean, tidy and free of offensive odour it housed a Cupboard for storing chemicals which must be kept locked at all times. The temperatures of fridges must be recorded on a daily basis and records maintained for inspection purposes. Staffing (Standards 31 – 36) Five of the six standards were assessed. One standard had minor shortfalls, some employees have completed some of the basic Health & Safety courses but staff responsible for medication must receive accredited training. Four of the standards had major shortfalls. The manager must provide all staff with a Job Description. A staff rota of current and past shifts must be available, all staff must receive regular supervision at least six times a year and staff must not be recruited until all relevant checks, CRB, references, health clearance, application form and identity documents have been gathered and the prospective employee is deemed a fit person to work in the care home. Conduct and Management of the Home (Standards 37 – 43) Four of the Seven standards were assessed. One of the standards had minor shortfalls as the home although safely storing service user files, records must be kept up to date. Three of the standards had major shortfalls; The home must develop plans and implement them on how they record any consultation with service users; although some policies and procedures are in place the home must ensure all required policies are in place and meet with regulations. The home has developed Risk Assessments for the premises, they need to be fully completed, signed, dated and regularly reviewed with comments recorded. The monthly emergency light tests must be completed, they were not available at the time of inspection. The fire evacuation procedure must be amended to include assembly point, fire exits and designated persons. The Garage must have the highly flammable paint and petrol moved if it is to remain a designated smoking area for service users alternatively an alternative hazard free area must be allocated.Bamville Road (1)Page 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 15 (1) (2) (a) to (d) The home must develop comprehensive care plans that meet all aspects of service users needs; such documentation is subject to review at least every six months or when circumstances change. The home must document within the care plans the process regarding the right of service users to make informed decisions. The home must demonstrate how service users are encouraged and offered opportunities to participate in the day-to-day running of the home and to contribute to relevant policies and procedures. The home must undertake risk assessments for service users, staff, the premises, food, fire and infection control. Such documentation is subject to regular review or when circumstances change. The home must collate the duty rota to comply with the Working Time Regulations 1998. The home must operate a robust recruitment system by obtaining completed application form, two satisfactory references, photocopies of birth certificate and passport, a photograph and CRB check before employment is offered. The home must develop and provide all staff with job descriptions. Within 2 weeks and ongoing Within 2 weeks and ongoing Within 2 weeks and ongoing3YA6412 (2)YA7524 (1) (a) &YA8613 (4) (a) to (c)YA42Within 2 weeks and ongoing817(2) Schedule 4 (7) &18 (1) (a) 19 (1) to (5) Schedule 2 18 (4)YA33Within 2 weeks and ongoing9YA34Within 1 month and ongoing Within 1 month10YA31Bamville Road (1)Page 8 1118 (1) (c)YA35The home must provide a structured programme of induction that reflects the content of the LDAF training and demonstrate that such has been carried out. The home must undertake and document monthly checks of the emergency lighting system. The home must develop all required policies and procedures as listed in Appendix 3 of the National Minimum Standards. Such documentation is subject to review at least annually or when circumstances change. Medication may only be administered by staff who have completed training in safe medication provided by a person competent to do so. The home must maintain records of such training for inspection. The home must compile an inventory of each individual’s personal belongings, such documentation requires ongoing up dating. The home must document the opportunities offered to service users to maintain and develop social, emotional, communication and independent living skills. The home must document the range of leisure activities offered to service users and their personal preferences. Details of links with family and other relevant persons must be documented within individuals care plans. The fire procedure requires further development to include what to do, how to raise the alarm, how to move service users and the designated person for each shift. Staff must receive training in Adult Protection by a person competent to do so and a record of such training must be maintained for inspection. Staff must be provided with training in epilepsy awareness by a person competent to do so. The home must maintain records of such training for inspection.Within 1 month and ongoing Within 1 month and ongoing Within 1 month and ongoing1223 (2) (p)YA421412 (1)YA401513 (2)YA20Within 6 weeks1617 (2) Schedule 4 (10)YA23Within 1 month and ongoing Within 1 month Within 1 month and ongoing Within 1 month and ongoing Within 1 month1816 (2) (m)YA111916 (2) (m) & (n)YA142023 (2) (i)YA152123 (4 )YA422213 (6)YA23Within 6 weeks2318 (1) (c)YA35Within 2 months Page 9Bamville Road (1) 2418 (1) (c)YA35Staff must be provided with training in diabetes awareness by a person competent to do so. The home must maintain records of such training for inspection. Staff must receive formal supervision at least six times per year (pro rata for part time staff) that is fully documented, an annual appraisal must also be included. The home must develop a statement of purpose and on completion of such document forward a copy the NCSC. The home must develop a service user guide in an accessible format and on completion supply a copy to each service user. The home must provide each service user with a contract/statement of terms and conditions as specified within Standard 5.2 The home must hold staff meetings at least six times per year and the minutes collated circulated accordingly. The home must provide two comfortable chairs in each bedroom. The home must provide staff with training in the ageing process by a person competent to do so. The home must maintain records of such training for inspection. The home must arrange for an electrical wiring examination to be carried out and a copy of the certificate forwarded to the NCSC. The home must develop a policy regarding COSHH and maintain a file on the COSHH products used within the home.Within 2 months Within 2 months and ongoing Within 2 months2518 (2)YA362617 (1) Schedule 4 4 (1) (a) to (c) 4 (2) 5 (1) (a ) to (f ) 5 (2)YA127YA1Within 2 months Within 2 months Within 2 months and ongoing Within 2 months Within 2 months285 (1) (c)YA52918 (4)YA333016 (2) (c)YA263118 (1) (c)YA213313 (4) (a)YA42Within 2 months Within 2 months and ongoing3413 (4)YA42Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Bamville Road (1) Page 10 Standard 1 2 3 4 YA40 YA42 YA17 YA19 All policies and procedures should be dated in order to assist reviews be conducted at least annually. The home should develop a rolling programme of maintenance. The home should produce four-week menu and oversee the variety of food provided. The home should develop a policy regarding smoking, alcohol and drugs that is relevant to both staff and service users.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Bamville Road (1)Page 11 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, the National Minimum Standards and the relevant sections of the Children’s Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action The home must develop comprehensive care plans following consultation with service users, that meet all aspects of service users needs; such documentation is subject to review at least every six months or when circumstances change. The home must document within the care plans the process regarding the right of service users to make informed decisions. The home must demonstrate how service users are encouraged and offered opportunities to participate in the day-to-day running of the home and to contribute to relevant policies and procedures. The home must undertake risk assessments for service users (with specific details on health conditions such as Epilepsy, Diabetes and Poor Mobility), staff, the premises, food, fire and infection control. Such documentation is subject to regular review or when circumstances change. All risk assessments must be dated and signed by staff and service user if possible and / or next of kin.115 (1) (2) (a) to (d)YA630/6/04212 (2)YA730/6/04324 (1) (a) & (b)YA830/6/04413 (4) (a) to (c)YA9YA4211/6/04Bamville Road (1)Page 12 517(2) schedule 4 18 (1) (a)YA33The home must collate the duty rota to comply with the Working Time Regulations 1998. Requirement of Last Inspection and not assessed at this inspection and is carried forward. The home must operate a robust recruitment system by obtaining completed application form, two satisfactory references, photocopies of birth certificate and passport, a photograph and CRB check before employment is offered. The home must develop and provide all staff with job descriptions. The home must provide a structured programme of induction that reflects the content of the LDAF training and demonstrate that such has been carried out. Requirement of Last Inspection and not assessed at this inspection and is carried forward.11/6/04619 (1) to (5) YA34 Schedule 231/5/04 and ongoing717(2) Schedule 4(6)(e)YA3131/5/04 and ongoing818 (1) (c)YA3531/5/04 and ongoing923(4)(a)(c)YA42The home must undertake and document monthly checks of the emergency lighting system. The home must develop all required policies and procedures as listed in Appendix 2 of the National Minimum Standards. Such documentation is subject to review at least annually or when circumstances change. Requirement of Last Inspection and not assessed at this inspection and is carried forward. The home must compile an inventory of each individual’s personal belongings, such documentation requires ongoing up dating. Requirement of Last Inspection and not assessed at this inspection and is carried forward.31/5/041012(1)YA4030/7/041117 (2) Schedule 4 YA23 (10)31/5/04Bamville Road (1)Page 13 1216 (2) (m)YA11The home must document the opportunities offered to service users to maintain and develop social, emotional, communication and independent living skills. The home must document the range of leisure activities offered to service users and their personal preferences. Details of links with family and other relevant persons must be documented within individuals care plans. The fire procedure requires further development to include what to do, how to raise the alarm, how to move service users and the designated person for each shift. Staff must receive training in Adult Protection by a person competent to do so and a record of such training must be maintained for inspection.30/6/041316 (2) (m) & (n)YA1430/6/041423 (2) (i)YA1530/6/041523 (4 )YA4230/5/041618(1) 13 (6)YA2330/6/041718 (1) (c)YA35Staff must be provided with training in epilepsy awareness by a person competent to 30/6/04 do so. The home must maintain records of such training for inspection. Staff must be provided with training in diabetes awareness by a person competent to do so. The home must maintain records of such training for inspection. Staff must receive formal supervision at least six times per year (pro rata for part time staff) that is fully documented, an annual appraisal must also be included. The home must develop a statement of purpose and on completion of such document forward a copy the NCSC. Requirement of Last Inspection and not assessed at this inspection and is carried forward.1818 (1) (c)YA3530/6/041918 (2)YA3630/6/042017 (1) Schedule 4 YA1 4 (1) (a) to (c) 4 (2)30/5/04Bamville Road (1)Page 14 215 (1) (a ) to YA1 (f ) 5 (2)The home must develop a service user guide in an accessible format and on completion supply a copy to each service user. Requirement of Last Inspection and not assessed at this inspection and is carried forward. The home must provide each service user with a contract/statement of terms and conditions as specified within Standard 5.2 The home must hold staff meetings at least six times per year and the minutes collated circulated accordingly. Requirement of Last Inspection and not assessed at this inspection and is carried forward. The home must provide two comfortable chairs in each bedroom. Unless it is the service users wish or a risk assessment states otherwise. This must then be recorded on a care plan and subsequently reviewed. Requirement of Last Inspection and not assessed at this inspection and is carried forward. The home must provide staff with training in the ageing process by a person competent to do so. The home must maintain records of such training for inspection.30/5/04225 (1) (c)YA530/5/042318 (2)YA3330/7/042416 (2) (c)YA2630/7/042518 (1) (c)YA2130/6/042613 (4) (a)YA42The home must arrange for an electrical wiring examination to be carried out and a copy of the certificate forwarded to the NCSC. Immediate and Requirement of Last Inspection and not ongoing assessed at this inspection and is carried forward. The home must develop a policy regarding Immediate COSHH and maintain a file on the COSHH and products used within the home, including data ongoing sheets and Risk Assessments. Activity programmes must be developed for service users that includes information of how the Service User was assessed and what outcome the activity is to achieve.2713 (4)YA422816(m)(n)YA1130/6/04Bamville Road (1)Page 15 2916(m)(n)YA14The home must consult service users views, likes and dislikes and include them where safe or risk assessed, with regular review into Care Plans and Activity Programmes. All staff must with support and sensitivity to service user Health and Safety consult the service user, giving information as to why certain decisions must be taken by the Manager to protect where reasonable the Health and Safety of service users and staff.30/6/043018(1)(a)YA42 YA31Immediate and ongoing3118(1) 13(2)YA20The manager must make arrangements for all staff involved in the receipt, storage, administration, recording, handling and disposal of medication to complete an 27/8/04 Accredited Medicines Training course. All certificates must be retained on staff files for inspection. The home must complete a Risk Assessment for any Service User self administering medication, ensuring regular reviews take place, this must also include Compliance Checks. The home must detail within its Statement of Purpose the arrangements made for dealing with complaints. The homes Adult Protection Procedure must be reviewed and amended to comply with the “No Secrets” document issued by the Dep’t of Health. The home must record fridge and freezer temperatures everyday and retain records.3213(2)YA2030/6/04334(1)(c)YA2230/5/043413(6)YA2330/6/043513(3), 16(2)(g) 13(4)(c) 16(2)(g) 17(2) schedule 4 (7) 13(4)(a)(c)YA30Immediate and ongoing36YA30Any item of food removed from its original Immediate packaging must be labelled and dated when it and is put back in the fridge. ongoing The home must have a current staff rota in place and retain all previous rotas, these must be made available for inspection All Risk Assessments for the building must be dated and signed, dates of review and comments must be included. Immediate and ongoing 30/6/0437YA3338YA42Bamville Road (1)Page 16 3923(4)(a)(b) (c)(d)(e)YA42The homes Fire Risk Assessment must be completed and all staff informed of its contents. The home manager must identify which member of staff on duty is designated to deal with emergencies such as fire. All chemicals used in the home must be stored in a locked cupboard. (COSHH Cupboard). The home must remove the fridge freezer from the rear garden to a safer more appropriate place.30/5/04 Immediate and ongoing Immediate and ongoing 30/5/044023(4)(a)(e)YA424113(4)(a)YA424223(1)(a)YA424323(4)(a) &13(4)(a)( c).YA42The designated smoking area in the garage Immediate must have either the highly flammable paint and and two motorbikes removed or a new hazard ongoing. free designated smoking area identified.Bamville Road (1)Page 17 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * 1 2 3 4 YA40 YA42 YA17 YA19 All policies and procedures should be dated in order to assist reviews be conducted at least annually. The home should develop a rolling programme of maintenance. The home should produce four-week menu and oversee the variety of food provided. The home should develop a policy regarding smoking, alcohol and drugs that is relevant to both staff and service users.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling • Pre-inspection Questionnaire • Records • Care Plans / Care Pathways • Meals • Activities • Other enter details here ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Bamville Road (1) YES NO NO YES YES NO NO NO YES NO YES NO YES YES NO NO NO YES NO YES Page 18 Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) 1 0 0 NO NO YES YES 4 0 24/03/04 12.30 2.25The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.Bamville Road (1)Page 19 Choice of HomeThe intended outcomes for the following set of standards are: • • • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 – 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives, philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Key findings/Evidence Not assessed. Transport, toiletries, day trips, holidays, hairdressers 0 Standard met?Standard 2 (2.1 – 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user using an appropriate communication method, and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? All three Service users had on file a full assessment prior to their admission to the home. All assessments were completed by the Social Services Department.Bamville Road (1)Page 20 Standard 3 (3.1 - 3.10) The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? Service user files included recorded information on access to all health professionals including GP, dentist and opticians. Consultant psychiatrist information was available on files. One service user plan identified that he has epilepsy, however an appropriate care plan and risk assessment was not available. Staff training files gave no evidence that staff had received specific training in the care of epilepsy. The home does not use assessments tools specific to the care of service users with Learning Disabilities. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis, before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? Not assessed.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? Not assessed.Bamville Road (1)Page 21 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: • • • • • 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.Standard 6 (6.1 – 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? All service users have care plans in place. However, there is no evidence of an agreement or consultation, service users have not signed the plans. All plans are basic and cover personal hygiene and support needed, personal skills, medical conditions (shortness of breath) and making own choices. The plans did not include actions service users and staff need to take to meet the needs of the service users. Individual plans were not seen to be written in sufficient detail to enable the reader to determine whether assessed needs and preferences were being met. Activity programmes for all service users were on all service users individual files, they were very basic and did not detail how an independent lifestyle is encouraged with activities in the home. Standard 7 (7.1 – 7.7) Staff respect service user’s right to make decisions and that right is limited only through the assessment process, involving the service user and as recorded in the individual Service User Plan. 1 Key findings/Evidence Standard met? Service user plans contained no evidence that service users were given the opportunity to make decisions, be involved in the assessment process and receive information about the services that are available. CSCI have not received a Statement of Purpose detailing services provided at the home, this was a requirement of the last inspection. Inspectors in conversation with a service user found that he had some control of his finances, he had money to spend and often used the local shops and he advised inspectors that he had sold some personal items. On discussing this with staff they were unaware of what the service user had sold. The home must maintain an inventory of possessions.Bamville Road (1)Page 22 Standard 8 (8.1 – 8.5) The registered manager ensures that service users are offered opportunities to participate in the day-to-day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? Not assessed.Standard 9 (9.1 – 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. 1 Key findings/Evidence Standard met? A collective risk assessment for travelling on local buses was seen by inspectors, the risk assessment was clear with actions to be taken. However, the assessment had no reviews and no service user involvement. The assessment was not dated or signed. The inspectors were therefore unable to determine whether the assessment was relevant to the service users current needs. Risk Assessments regarding the health needs of service users were not available on service users files. Inspectors found information on service user files regarding medical conditions these included epilepsy, shortness of breath (caused through smoking) and mobility needs of service users, however this information was not seen to be included within service users individual plans. Standard 10 (10.1 – 10.6). Staff respect information given by service users in confidence and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998 and in the best interests of the service user. 0 Key findings/Evidence Standard met? Not assessed.Bamville Road (1)Page 23 LifestyleThe intended outcomes for the following set of standards are: • • • • • • • 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 user’s rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 – 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 2 Key findings/Evidence Standard met? All three service users had activity programmes. Information of how they were assessed, service user involvement, intended outcomes of activities (what assessed need will it meet) were not recorded. One service user in conversation with inspectors was very positive about how he is able to visit friends in the local community and use the local shops.Standard 12 (12.1 – 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities 0 Key findings/Evidence Standard met? Not assessed.Bamville Road (1)Page 24 Standard 13 (13.1 – 13.5) Staff support service users to become part of, and participate in the local community in accordance with assessed needs and the individual Plans. 2 Key findings/Evidence Standard met? Inspectors found that service user plans did include some information regarding participation in the local community, this was recorded on activity programmes. The activity programmes identified the use of local amenities, the evidence of assessments prior to formulating an activity programme were not in place. Inspectors were able to discuss with a service user who had returned by himself from the dentist his involvement within the local community, his response was very positive and he was clearly happy with his activity programme. Standard 14 (14.1 – 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. 1 Key findings/Evidence Standard met? The home has not developed a Statement of Purpose identifying appropriate leisure activity for the service users, which was a requirement of the previous inspection. Inspectors were unable to find within service user files any information pertaining to likes and dislikes, thus hobbies and interests of service users had not been recorded. Records of entertainment and activity brought into the home were not inspected.Standard 15 (15.1 – 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not assessed.Bamville Road (1)Page 25 Standard 16 (16.1 – 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not assessed.Standard 17 (17.1 – 17.9) The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not assessed.Bamville Road (1)Page 26 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: • • • • 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 procedure for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 – 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? Not assessed.Standard 19 (19.1 – 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No of service users with pressure sores at the time of inspection (from information taken from care notes) XX2 Key findings/Evidence Standard met? The service user plans and daily records were in place and there was evidence that service users had regular contact with their GP, Optician and Dentist. At the time of the inspection a service user was returning from an appointment with the Dentist and staff informed inspectors they were escorting a service user to a chiropody appointment. Service user plans did not include specific assessments of need, one service who was recently seen by an Occupational Therapist needed to have a moving and handling risk assessment and care plan for mobility and arthritis. One service user who has epilepsy had no risk assessment and an incomplete care plan pinned to the office wall. The home must ensure that all service user records are stored securely ensuring confidentiality is not breached. An appropriate risk assessment and care plan is required on the service user file.Bamville Road (1)Page 27 Standard 20 (20.1 – 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 2 Key findings/Evidence Standard met? Medication was inspected and records were found to be up to date, medications into the home had been recorded, all administrations had been signed for and amount of tablets remaining were correct. Copies of the original GP prescription had been taken and sample signatures of staff administrating medicines were available. Staff were found to sign the Medication Administration Record (MAR) for one service user who was out at a Day Centre and whilst at the Day Centre he administers his own medication. It is in a bottle labelled by the home and includes service user name and name and dosage of medication. Secondary dispensing of medication must not be the homes practice and can only completed by an individual trained to do so. The home must contact the Pharmacy and make appropriate arrangements for dispensing the medication for the service user to administer whilst at the Day Centre. Staff were advised that a Risk Assessment for Self Administration of Medication must be completed. The system was Boots Monitored Dosage System, and staff were requested to use the correct “key codes” for entry on the MAR when this service user is at the Day Centre or to clearly identify at what times the service user self-administers on the MAR. The home has a Homely Medicines policy in place; at time of inspection no records were seen recording administration of homely medicines. Standard 21 (21.1 – 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Not assessed.Bamville Road (1)Page 28 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: • • Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 – 22.7) The registered person ensures that there is a clear and effective complaints procedure which includes the stages of and times-scales for the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days X X X X X X X 2 Key findings/Evidence Standard met? The home has a complaints policy, the complaints record was found to have no entries in it and the Commission for Social Care Inspection has not received any Complaints regarding the Home in the past 12 months. The home has not developed its Statement of Purpose and has no evidence seen by inspectors of how service users have been informed of the arrangements made for dealing with complaints. Staff must be briefed with regard to these changes.Bamville Road (1)Page 29 Standard 23 (23.1 – 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence, or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists NOX1 Key findings/Evidence Standard met? The home has an Adult Protection Procedure, the procedure does not meet with the Department of Health guidance on “No Secrets” and the Birmingham City Council Multi Agency Guidelines. The procedure must be reviewed to comply with the “No Secrets” document and the Birmingham City Council Multi Agency Guidelines. It must also have included information on contacting Social Services, Police and CSCI. Current information within the procedure does not cover what staff must and must not do, and this has to be included.Bamville Road (1)Page 30 EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 24 (24.1 – 24.13) The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The decoration of the home is pleasant and well maintained. It appeared to be clean and free from odour. The communal areas on the ground floor are domestic in style; furnishings and fittings were noted to be of satisfactory standard and unobtrusive. A range of comfortable seating was available and appropriate dining facilities. The home should develop a plan for the maintenance and renewal of fabric and decoration of the premises, with records kept of such works carried out.Bamville Road (1)Page 31 Standard 25 (25.1 – 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) – single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence Not assessed. YES NO NO 3 1 0 0 Standard met? 0 3 00 0 0 0Bamville Road (1)Page 32 Standard 26 (26.1 – 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Not assessed. Standard met? 0Standard 27 (27.1 – 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? Not assessed.Standard 28 (28.1 – 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? Not assessed.Bamville Road (1)Page 33 Standard 29 ( 29.1 – 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The home has made adaptations for one service user with mobility needs, a handrail has been fixed by the rear door to assist access and egress. The registered provider/manager should give some consideration to the ageing process and future needs of the service users who live at the home. The needs of service users must be kept under review to ensure that changing needs are recognised and met. This must be included in the home’s statement of purpose.Standard 30 (30.1 – 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 2 Key findings/Evidence Standard met? The home has a laundry which was domestic in style with one washing machine and one tumble dryer adequate to meet the needs of the service users. The cupboard storing chemicals (COSHH Cupboard) must have a lock fitted. The home was seen to be free from any offensive odour and appeared clean and tidy. The kitchen showed good standards of hygiene, it was clean and well organised. The fridge contained food items that must be labelled with the date of opening in order to avoid food contamination. The temperatures of the fridge had been recorded but only up until January 2004. It is required that fridge temperatures be recorded a minimum of once a day. All staff have recently completed a Food Hygiene course.Bamville Road (1)Page 34 StaffingThe intended outcomes for the following set of standards are: • • • • • • 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.Standard 31 (31.1 – 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 1 Key findings/Evidence Standard met? Three sampled staff files contained no job descriptions. Staff were observed to have developed good relationships with the service users they support however the registered manager must take board her role and keep service users informed of decisions that must be made to protect their Health & Safety. The manager was seen by inspectors to be reluctant to inform a service user that the Garage could not be used as a designated smoking area as it had been used to store highly flammable liquids (petrol and paint).Bamville Road (1)Page 35 Standard 32 (32.1 – 32.6) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing 0 0 0XX2 Key findings/Evidence Standard met? Records of staff training were available, all staff have recently completed Food Hygiene Training and all staff who administer medication have received training on the Boots Monitored Dosage System, the Manager must provide accredited medication training for these staff. Fire training for all staff had recently been completed, this must be maintained at regular intervals. Inspectors were shown documents confirming that all staff are booked onto First Aid Training on the 24TH April 2004. The manager updated inspectors of NVQ training for staff, however inspectors saw no documentary evidence.Bamville Road (1)Page 36 Standard 33 (33.1 – 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. 1 Key findings/Evidence Standard met? The manager was unable to produce a current or recent staff rota for inspectors to assess. The manager informed inspectors of staff working early, late and on-call duties. This is an outstanding requirement from the last inspection. Failure to comply with statutory requirements may lead the commission to take enforcement action. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? Three individual staff files were sampled during inspection. All were found not to contain required information as listed under Schedule 2 of the Care Home Regulations 2001. All files had one or more of the following documents missing; Identity documents, Criminal Records Bureau check, Application form, References, Job Descriptions, Contracts and Supervision Records. The registered manager must ensure that all checks and documents are available within Staff Files. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not assessed.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 1 Key findings/Evidence Standard met? The three sampled staff files had no evidence that staff receive regular supervision with a target of at least six times a year, no annual appraisal of staff performance was available on the files.Bamville Road (1)Page 37 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 37 (37.1 – 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent. Key findings/Evidence Not assessed. NO 0Standard met?Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 1 Key findings/Evidence Standard met? The manager was seen by inspectors to be reluctant to discuss Health and Safety concerns of using the garage as a designated smoking area with a service user, and asked the inspectors to discuss this with the service user. The manager felt it was not appropriate to designate another smoking area until it had been discussed with other service users first. Which is positive; however the manager must be mindful of her responsibilities to safeguard the welfare of the service user who smokes. The three service user files had no evidence that service users are consulted about service delivery and no forum for service users to raise concerns was available.Bamville Road (1)Page 38 Standard 39 (39.1 – 39.10) Effective quality assurance and quality monitoring systems based on seeking the views of service users are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? Not assessed.Standards 40 (40.1 – 40.6) The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Younger Adults. 1 Key findings/Evidence Standard met? The homes policy on Adult Protection was seen by inspectors, it must be amended to comply with the Department of Health “No Secret” document paper. Ensuring that Managers do not investigate complaints or allegations, that information of who to contact (National Care Standards Commission, Social Services Dept, Police) is included, it must include actions for staff to undertake if allegations are made about the Manager.Standard 41 (41.1 – 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained up to date and accurate. 2 Key findings/Evidence Standard met ? Service user files were securely stored in the office at the top of the building, this office also securely stored all records pertaining to the service and staff. The homes records for service users and staff will require significant development to fully meet the standards required.Bamville Road (1)Page 39 Standard 42 (42.1 – 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 1 Key findings/Evidence Standard met? Inspectors examined risk assessments for the home and many of the documents were unsigned and not dated these included, Fire, Accidents, Control of Substances Hazardous to Health and Building Security. The Fire Risk Assessment document had not been fully completed. The manager maintained the Fire Folder to a good standard, this included up to date records of Fire Alarm System Inspection, Fire Extinguisher Test and Service, and Emergency Lighting Service. Recent Fire Drills were recorded and information about service user responses was recorded in detail. The weekly Fire Alarm Tests were up to date and well maintained. The home must ensure that the records of Monthly Emergency Light tests are available for inspection. The home must ensure that a designated staff member is identified on each shift to take control of any emergency situation, such as Fire. The Gas Service Certificate was up to date and no issues were recorded. Portable Appliance Testing had been completed in August 2003. A requirement from the last inspection was the home must ensure an electrical hard wiring examination be completed, with a copy of the certificate forwarded to the commission. This has yet to be received and thus is a requirement of this inspection. The Homes Fire Evacuation procedure on the office wall must be amended to include; a stated Assembly Point, where the Fire Exits are and include how to move / make safe individual service users. Inspectors found food items in the kitchen fridge that had not been labelled and the Fridge Temperature record had not been maintained, last entry was in January 2004. In the laundry the COSHH cupboard had no lock on the door and chemicals stored had no Risk Assessments or Data Sheets. The laundry and kitchen were seen by inspectors to be clean and hygienic. The Garden had a fence panel that was missing, access to neighbours garden was not controlled; during the inspection the Manager replaced this panel. A fridge freezer was being stored in the Garden and this must be moved. The Garage was being used as the designated smoking area for the home, the garage also stored highly flammable combustibles (two motor bikes - petrol and paint) the manager was left immediate requirements to make this situation by either clearing the garage of all combustibles or by reallocating the designated smoking area.Bamville Road (1)Page 40 Standard 43 (43.1 – 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Not assessed.Bamville Road (1)Page 41 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateJulie Preston Sean Devine Jane RumbleSignature Signature SignatureBamville Road (1)Page 42 PART D(where applicable)LAY ASSESSOR’S SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Bamville Road (1)Page 43 PART EE.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 24th March 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the NCSC in response to provider comments: Amendments to the report were necessary Bamville Road (1) NO Page 44 Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan within one month, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publication Action plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan Other: enter details here NO NO NO YESBamville Road (1)Page 45 E.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Bamville Road (1)Page 46 - 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. 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