Inspection on 01/03/06 for Mrs Linda Nicholls

This inspection was carried out on 1st March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mrs Linda Nicholls 19/02/08

Mrs Linda Nicholls 19/02/07

Mrs Linda Nicholls 20/10/05

Mrs Linda Nicholls 28/02/05

Mrs Linda Nicholls 31/08/04

Mrs Linda Nicholls 11/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Mrs Linda Nicholls 573 Chester Road Castle Bromwich Birmingham West Midlands B36 0JU Lead Inspector Alison Stone Unannounced Inspection 1st March 2006 10:45 Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mrs Linda Nicholls Address 573 Chester Road Castle Bromwich Birmingham West Midlands B36 0JU 0121 240 7786 0121 240 7786 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Linda Nicholls Mrs Linda Nicholls Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th October 2005 Brief Description of the Service: 573 Chester Road is registered as a Care Home for Younger Adults, providing care and support for no more than five people with Learning Disabilities. Mrs Nicholls is the owner of the service and is also registered as the Manager. The home is a detached 5 bedroom family house on a main road on the border of the Castle Bromwich and Smiths Wood areas of Birmingham and Solihull. The residents benefit from single bedroom accommodation and receive care and support within a domestic living environment. Local shops and amenities are a short distance away, and a local day centre is within walking distance. The main shopping area of Chelmsley Wood is a short drive away. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a morning and lunchtime of one day. The inspector collected information to form the basis of judgements in this report in a number of ways; she spoke to a person who lived there, the registered manager and the deputy manager. Some service users and staff records were looked at, along with records relating to the management of the home; some aspects of health and safety were looked at, medication and some policies. The inspection focused on the last requirements and recommendations made and what progress had been made towards these since the last inspection. The previous inspection was in October 2005 covered the majority of the core standards, so for the purposes of this inspection only core standards that were previously not assessed were looked at and the inspection focused on the care planning process and work made towards this and the previous requirements. This report should be read alongside the report of the previous inspection of 20 October 2005. The inspector would like to extend her thanks to everyone who helped with this inspection. What the service does well: The home provides a homely, spacious comfortable environment for the people to live in, and is nicely decorated. The staff provide consistent support to five people who live there, through a small generally well-established staff team. The staff work hard to meet the needs of the people who live there and provide them with meaningful activities both during the day and in the evening. A lot of care has been taken by the manager to ensure that the cultural needs of two of the people who live there are being met effectively. People are provided with several holidays a year. The staff were observed to have a positive and respectful relationships with the people who lived there. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 6 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. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5 The service users are supported with a social services assessment prior to moving in, this enables service users individual needs and aspirations to be identified. To help service users with the transition of moving into the home, they are fully supported to visit and experience the home prior to moving in. Each service users has an individual contract, this needs some further development. EVIDENCE: Three service users files were sampled for the purposes of this inspection. All service users have a completed social services care plan prior to moving in. From this the owner/manager supports service users to have further care plans about their individual needs and develops risk assessments. The deputy manager talked about the introduction of two service users, who are brothers when they first moved in. The owner/manager and staff have worked hard to support the service users through a complex transition, via a long and supportive introduction programme. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 9 Since moving in the owner/manager has continued to look at supporting the service users needs, particularly their cultural needs and employs an Afro Caribbean cook to come in twice a week to cook with the service users, she has also worked hard to ensure their religious needs continue to be met. The service users files sampled indicated a contract was in place, this needs some further work to ensure the cost of the home per week is detailed and any ‘top up’ cost the service users pay. It also needs to include the arrangements for service users holidays each year, and what cost service users have to pay if any and if staff support service users holidays and what the arrangements are for this. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Service users are supported with detailed assessments prior to admission, the needs identified are reflected in care plans. Enabling service users to be fully supported with their needs. Service users are supported to have all the assistance they need to make decisions. Service users are supported to ‘feel’ involved in the care they receive, through regular consultation in aspects of their care. Service users are encouraged to be as independent as possible and are supported with this, with some risk assessments. This process is not comprehensive. There are areas that need further development to ensure all risks are identified and appropriate action is taken. Service users know that information about them is handled appropriately. Giving them confidence to discuss problems and issues with the staff team. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 11 EVIDENCE: Three service users’ files were sampled as part of the inspection. The owner/manger had worked hard to take on the points from the last inspection and develop new systems of care planning that include dates and signatures on reviews indicating care plans are current and accurate. The care plans need further development, to ensure service users needs are detailed in such a way that staff can easily meet all service users needs and personal preferences. Care plans should include a section that details the actions staff need to take to ensure this happens and they should be cross referenced with risk assessments, so the reader is easily guided from one to the other. This will support the service users to have a whole package of care. Whilst care plans are dated and signed as reviewed this should also include comments, so outcomes of reviews of care can be included indicating when things in care plans need to change or if they are to remain on-going. The owner/manager said and staff have several processes in place to ensure service users are involved in their care, there are regular service user meetings, key worker meetings, reviews at the day centre, Person Centred Planning meetings, led by the day centre and staff meetings which include discussions about service users needs. These are minuted but were not looked at during the inspection. It is recommended that these processes be further developed, to include service users being involved in their care plans and where possible service users should be supported to sign up to their plans of care. In the case where the service users are unable to do this, a relative/carer, service users representative should be involved. It was suggested that the owner/manager look to involve an independent facilitator of service users meetings, to support the service users with citizen advocacy. Whilst more work has been done on risk assessments, these too need some further development, in terms of providing more detail on what the risks are, and what control measures staff should take to minimise risks, they should be linked to care plans and involve the service users and/or their representative. There should be a section on risk assessments, which includes the opportunity to document outcomes of reviews. Reviews should happen regularly at least every six months, or before if a situation changes. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 12 During the inspection all interactions from the staff with the service user who was there, were positive and respectful. All information relating to the service users and management of the home was found to be appropriately stored. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 15, 16, 17 Service users have opportunities for personal development. Service users are encouraged and supported to have appropriate personal, family relationships. Service users rights and responsibilities are generally respected and recognised in their daily lives. Service users are offered a healthy diet. EVIDENCE: The owner/manger and staff work hard to ensure service users can participate in a range of activities of their choice. Two-service user who moved in from another area have been supported to pursue and continue their religious practices and the staff support this to happen every week. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 14 The owner/manager has found a volunteer who she has had CRB checked to support the service users to attend church whenever they chose. Some work has started with the service users in the development of Person Centred Plans; the day centre has led this. It would be important for all service users personal development to be supported to all have a Person Centred Plan, detailing their aspirations for their own futures. All the service users have contact with their families, some on a regular weekly basis, some on an occasional basis. Three of the service users go on holiday with their families every year and enjoy close relationships with them. The owner/manager encourages the service users to see their families regularly and where possible will facilitate this. There is an ‘open door’ visiting policy and people are welcome to visit their family and/or friends as often as they like. Service users see their friends during the day at college, work and the day centres, they also go out three times a week in the evenings where they see their friends at clubs they attend. Service users are supported to have regular service users meetings and reviews, their rights and responsibilities could be further supported through involvement in key worker meetings and there own care plans. The inspector was not there during a mealtime, but it was noted service users have several pleasant areas to enjoy their meals in, like the conservatory and a well-maintained and developed garden area. Menu planners indicated service users can enjoy a choice of meals and that these are well balanced choices. Examination of the cupboards, fridge and freezer indicated that these were well stocked with a variety of foodstuffs. The owner/manger said there were some issues with one-service user accessing the fridge in a way that could cause infection control issues to the other people who use the fridge. It was discussed as he only uses the fridge to have snacks when he wants them, perhaps a small fridge could be purchased for his room, where he could keep the things he likes to have as snacks. This would then present no risk to others, and would remove the need to monitor the use service users make of the fridge and stop staff trying to restrict the Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 15 service users access to the food kept there, so compromising their independence in this area. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 Service users are supported to have their physical and emotional needs met, this could be further developed. Service users are protected by the home’s policies and procedures for dealing with medicines. The aging, illness and death of a service user could be further developed, to ensure these eventualities are handled with respect and how the individual would wish. EVIDENCE: Service users attend regular health appointments with their GP, optician, doctors, chiropodist and dentist. Whilst service users health needs are being met, it is recommended that a more proactive approach be taken towards the health of the service users, through a Health Action Planning process. This would support service users to have more understanding of their own health care needs and encourage them through this process to identify changes in their own health and recognise what is healthy and when and if changes in their health mean they need to seek assistance. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 17 Medication was not fully inspected, however it was noted that there had been no omissions on records since the last inspection, and the owner/manager said that now all medications were entered on the service users medication administration charts. It is recommended that all service users have on file, consent forms signed by the service users, demonstrating their agreement to them having their medication administered for them. It is also recommended that sheets be put in place for all medication, including PRN medication, demonstrating details of what condition the medication is given for and what possible side effects and contra-indications are present in the medication, this would then guide staff with the safe administration of medication. All staff have completed the safe medication handling training course at Solihull College recently. Service users files that were sampled, demonstrated some work had been done around individual wishes in the event of their death, it is recommended that this be expanded to include all plans/arrangements for service users wishes in this event. It was recommended that where it was felt this was inappropriate or where the service user did not wish to have this discussion then that should be respected, and it may be possible to discuss this with relatives/carers. It was suggested discussions about aging and illness affecting service users could be incorporated into the Health Action Plans. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users views are generally listened to and acted upon; the complaints policy needs to be developed. More work is required with staff to ensure they are competent in all their actions to recognise and protect service users from abuse, neglect and selfharm. EVIDENCE: The owner/manager had a complaints policy in place; this needs up dating to include CSCI contact details. This should be supported by a service users accessible complaints policy that each service users has a copy of, again this should detail CSCI’s contact details. It is recommended that the complaints policy and how and why service users should and can complain be discussed at a service users meeting. The owner/manager said that all the service users are able to complain if they wish and understand how to do this and are confident that they can complain and that their complaints and concerns would be taken seriously. Unfortunately during the inspection there were no service users available to discuss this with. The owner/manager said that she did not have a complaints log, this was discussed with her and it is required that she develops this for the service. A complaints log should include the date the complaint is made, the name of the Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 19 person making the complaint, brief details of what the complaint is and action taken to resolve the complaint. All letters and other records of the action taken as part of the complaint process should be held in a confidential place within the home, so that it can be looked at as part of an inspection, or in the case of an investigation into how a complaint was managed. It was recommended that the complaint log, be a complaint, compliment and comments log, so that comments and positive things said about the service by, service users, staff and relatives/cares can be included. Details of how to complain should be included in the Service User Guide and the Statement of Purpose. Only the manger has had any training in the area of Adult Protection and this was some time ago. All staff are required to complete training in this area, and then up date every two years to ensure they are fully aware of their responsibilities and obligations under the adult protection procedures, new staff must attend this course within six months of taking up post. Furthermore the manager must get a copy of the Local Authority’s guidelines in this area, and there must be a copy of the Departments of Health’s guidance in this area, detailed in the white paper ‘No Secrets’. All service users need to be supported to have financial risk assessments. The appointee to two of the service users is their aunt and there are some difficulties with this, in terms of the service users having access to their own money on a regular basis. It is recommended that the owner/manager contact social services to request a meeting to look at this situation and how to resolve this problem in the best interests of the service users. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26, 30 Service users bedrooms promote their independence. The home is clean and hygienic. EVIDENCE: Only one-service user was at home during the inspection, as all the other service users were out, pursuing their individual daytime activities. The service user who was at home, agreed to let the inspector spend some time in his room with him looking at his things. The room was nicely decorated and had lots of personalised belongings in reflecting his hobbies and interests. It was noted that the home was very clean and tidy and free from any unpleasant smelling odours. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35, 36 Service users benefit from clarity of staff roles and responsibilities. Service users are not fully supported by the staff team as more training is required to ensure a fully competent and qualified staff team and to ensure needs are appropriately met, both individually and as a group. Service users are supported and protected by the home’s recruitment policy and practices. Service users benefit from a well supported and supervised staff team. EVIDENCE: The owner/manager said two staff have recently left, which has caused some issues with covering shifts, meaning she has had to work more hours to cover the shifts than she usually does. There are two more staff starting work shortly, which should resolve the current staffing shortages. Three staff files were sampled for the purposes of this inspection, these were found to meet with schedule 2 of the regulations. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 22 Job descriptions were included on staff files and there was evidence that staff were supported with an induction programme when they first started work. The staff team have bi-monthly staff meetings, the last meeting minutes were not inspected on this occasion, as they couldn’t be accessed off the computer where they were held; some staff meeting minutes were seen on individual staff files. The owner/manager said that all staff are given their own copies of these meeting minutes. Some staff training has been undertaken recently in the area of medication training, and further training is booked. This is the first time formal training has been undertaken for the staff team. All staff must undertake formal training in statutory areas, like, manual handling, first aid, food hygiene, infection control, COSHH, adult protection, inhouse fire training and health and safety, this is not an exhaustive list. This should be further supported by specialist training for staff to meet service users individual and collective needs, in areas like, Health Action Plans, communication and Learning Disabilities. The manager said all staff have now got their NVQ level 2 and she and the deputy manager have their RMA’s. The manger said that she is now meeting her responsibilities to supervise staff at least six times a year; staff files sampled indicated supervision has taken place recently. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Service users benefit from a well run home. Service users’ views should underpin all self-monitoring, review and development of the service and a quality assurance process should be developed to ensure best practice. Some further work is required to the record keeping within the home; to ensure service users rights and best interests are safe guarded. Service users’ safety and welfare will not be fully protected until necessary work in the area of health and safety is completed. EVIDENCE: The owner/manager has been running the home for over five years and has been a consistent lead in this post; she is well supported by a deputy manager. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 24 Both work hard to ensure requirements from inspections are taken on board and met; they are both committed to developing the service in line with the service users needs and work hard to ensure they work within all Legislation. The owner/manager generally manages the home well, and there are in place all basic frame works to support the service to work within the regulations and meet the standards as detailed in the 2001 Care Home Regulations Legislation. The owner/manager needs to develop a quality assurance system that demonstrates the involvement of service users, relatives/carers, staff and other involved professionals, in commenting about their views on the service provided and produce an annual report from this. The owner/manager has an extensive list of policies and procedures in place to support the service; some of these were looked at as part of the inspection process. The complaints policy and the protection of Vulnerable Adults Policy were looked at and as detailed in the main body of the report, under standards 22 and 23 require some more work. The policies and procedures should be reviewed at least annually and signed and dated to indicate this has taken place. Some aspects of health and safety were looked at, focusing on the areas of the last requirements, fire drills now take place every six months, and fire tests are completed weekly. However a fire risk assessment needs to be undertaken for the premises; this should be further supported by ensuring service users have risk assessments on their files detailing the action staff need to take to support them appropriately in the event of a fire. Water temperatures need to be checked weekly and recorded as completed, this should involve checking all outlets. There needs to be a generic risk assessment in place for the hot water tap in the kitchen, to ensure service users are protected from scald injuries. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 3 LIFESTYLES Standard No Score 11 2 12 X 13 X 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 2 3 X 2 X 2 2 X Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA3 Regulation 12 Requirement The registered manger must completed some further work on care plans to ensure service users aspirations and needs are met. The registered manager must ensure service users have contracts that provide details of fees and details of holiday arrangements. These should be where possible signed by the service user, where this is not possible then service users representative could sign. The registered manager needs to ensure care plan documentation is developed as recommended in the main body of the report to ensure service users are fully supported with all their needs. The registered manager must ensure where service users are able they are supported to sign up to their individual care plans. The registered manager must ensure that the risk DS0000004553.V277503.R01.S.doc Timescale for action 01/08/06 2. YA5 5(b)(c) 01/07/06 3. YA6 15(2) 01/06/06 4. YA7 12(c) 01/08/06 5. YA9 13(4)(b) 01/08/06 Mrs Linda Nicholls Version 5.1 Page 27 7. YA11 16(2)(m) 8. YA16 12(4)(a) 9. YA20 13(2) 10. YA21 Sch3(3)(g) 11. YA22 22 4(11) assessment process is developed further to include, specific detail about risk presented and detail control measures staff should take to minimise risks. These should be reviewed at least six monthly and the notes from reviews should be recorded on these documents. The registered manager needs to ensure all service users are offered Person Centred Plans that identify individual aspirations, which staff can then support service users to achieve. The registered manager needs to ensure service users are actively involved in their key worker meetings and the development of service user care plans. The registered manager must ensure that the medication records have individual service user consent forms in place and medication protocols should be produced for all medication, to support staff with the safe administration of medication. The registered manager needs to look at working with service users through Health Action Plans to consider issues like aging and illness. Existing plans around service users wishes in the event of their death should be further developed to ensure their exact wishes in this area are captured. The registered manager must ensure a service users accessible complaints procedure is devised. This DS0000004553.V277503.R01.S.doc 01/09/06 01/08/06 01/06/06 01/09/06 01/06/06 Mrs Linda Nicholls Version 5.1 Page 28 12. YA23 13(6) 13. YA32 18(1)(a) Sch2(4) 14. YA35 18(1)(c) 15. YA39 24(1)(a)(b) (2)(3) should then be discussed with the service users, and each should have a copy. The existing complaints procedure needs updating to include CSCI’s contact address. The registered manager must ensure that she has a copy of the Birmingham Multi-agency guidelines on what to do in the event of an allegation of abuse. There also needs to be a copy of the DOH paper ‘No secrets’ available within the home. All staff must undertake training in this area. The registered manager must ensure that all staff are supported to have training in all statutory areas like, food hygiene, first aid, infection control, health and safety, COSHH, manual handling, Protection of Vulnerable adults, medication and specialist training as identified to meet the needs of the service users. The registered manager needs to develop a training matrix that details the all courses staff have undertaken, who provided the training and when a refresher course is due. There should be individual records of staff training with copies of training certificates kept on individual staff files. The registered manager must develop a quality assurance system for the service that included canvassing the views of the service users, relatives/carers, staff and involved professionals and produce an annual report. DS0000004553.V277503.R01.S.doc 01/05/06 01/10/06 01/10/06 01/11/06 Mrs Linda Nicholls Version 5.1 Page 29 16. YA41 17 17. YA42 18. YA42 19. YA42 The registered manager ensure all records are completed and kept up to date in areas of staff training, reviewing policies and procedures and the checking and recording of water temperatures. 23(2)(p) The registered manager must ensure a risk assessment is developed for the hot tap in the kitchen area, detailing action to protect service users from scalds. 23(4)(c)(iv)(e) The registered manager must ensure a fire risk assessment is completed for the premises and that all service users have individual risk assessments detailing what action staff should take to support them in the event of a fire. 23(2)(p) The registered manager must ensure that as well as checking of all water outlets once a week to ensure they remain with in the safe range of under 43°C, that this is also recorded as completed. 01/10/06 01/04/06 01/06/06 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA19 Good Practice Recommendations The registered manager should support all service users to have individual Person Centred Plans. The service users should be supported to have individual Health Action Plans. Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mrs Linda Nicholls DS0000004553.V277503.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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