Inspection on 23/06/05 for Natalie House

This inspection was carried out on 23rd June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Natalie House 03/11/08

Natalie House 05/12/07

Natalie House 17/01/07

Natalie House 17/11/05

Natalie House 18/03/05

Natalie House 25/05/04

Natalie House 27/01/04

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 Natalie House 14 Eachway Lane Rednal Birmingham B45 9LG Lead Inspector Gerard Hammond Unannounced 23rd June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Natalie House Address 14 Eachway Lane Rednal iBirmingham B45 9LG 0121 457 9592 0121 457 9592 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Alphonsus Homes Ms Novelet Stewart Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 18 March 2005 Brief Description of the Service: Natalie House is registered to provide accommodation, personal care and support for five adults with learning and physical disabilities. It is situated in a quiet residential area on the edge of the Lickey Hills in Rednal, Birmingham. The house is close to public bus routes and the shopping centre at Rubery is nearby also. The property is a purpose built bungalow and first opened in 1991. It is specifically designed to meet the needs of people with learning disabilities, who may also be physically disabled. Each single bedroom has en-suite facilities, including level entry shower, w.c. and wash handbasin. There is a large bathroom with spa bath and w.c., and a separate w.c. In addition there is a lounge giving access to the garden, a dining room, kitchen, separate laundry and office. The garden is enclosed and private, and includes both lawn and patio areas. There is limited off-road parking at the front of the house. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Direct observation and sampling of records (including personal files, care plans and safety records) was undertaken for the purposes of compiling this report. The Inspector met all the residents and conducted a formal interview with the Manager. Three other members of staff were seen informally, and a tour of the building was also completed. What the service does well: What has improved since the last inspection? What they could do better: Care plans need to be developed in such a way that it is possible to measure improvements and progress. Setting some goals, and then looking to see what has worked, and what needs to be changed, could achieve this. This should be done at least every six months. Ways of improving residents’ opportunities to communicate better should be actively explored. This might involve seeking expert professional advice and providing additional training and support for members of staff. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 6 The range and quality of people’s opportunities for social, educational and leisure pursuits should be evaluated, so as to better inform future care planning. Residents’ support needs for bathing need to be reviewed, so that informed judgements can be made about improving the Home’s bathroom facilities. Systems for monitoring and judging the quality of the service should be further developed, and put into place. 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. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 4 & 5 Current residents’ support needs have been assessed, and prospective residents would be given the opportunity to visit and stay at the home, before making a decision about taking up a placement. Residents’ contracts need to be reviewed in order to comply fully with Standard 5.2. EVIDENCE: There have been no new admissions since the last inspection, and the resident group has remained unaltered for a considerable time. The support needs of the residents were assessed appropriately at the time they came to live in the house. Conversations with the Manager indicated that, should a vacancy arise in the future, that steps would be taken to ensure that any prospective resident would have ample opportunity to visit and stay at the Home, prior to any decision being made about offering a place. Residents’ contracts need to be amended to include details of all costs and contributions, and all other necessary information indicated by Standard 5.2. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, & 9 Residents’ individual plans are in need of review to establish measurable goals, and to ensure that information essential to supporting each person effectively is recorded appropriately. Staff actively support residents to make decisions and exercise choice, and encourage risk taking in a responsible manner. EVIDENCE: Residents’ personal records contain a lot of quite detailed information about people’s care needs and guidance about how these might be met. Individuals’ care plans are in need of review to bring them fully up to date and to ensure that they are effective working documents. Care plans should set targets with measurable outcomes, which can subsequently be evaluated at review. Care plans and risk assessments indicate that reviews have taken place, but only show dates and initials. Individuals’ whole “care packages” should be reviewed at least six monthly, with written records indicating who takes part, and how decisions are reached. In care plans the detail of support to be given needs to be specific. One resident is said to indicate bathing requirements non-verbally, but no Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 10 information follows about how this is done. Another care instruction states “must be checked”, but no indication is given with regard to frequency. One man’s care plan has no detail at all under “shaving”. Risk assessments should be cross-referenced to the component(s) of the care plan(s) to which they relate, and vice versa, so that the reader is directed simply from one to the other. A good practice recommendation was made that these should be indexed and “tidied up”, with any information that is no longer current being archived or disposed of as appropriate. Of particular importance for this group of residents is guidance within their individual plans to support their communication. It is recommended that each person’s communication guidelines should be placed in a prominent position on his or her care plan in order to help support staff to engage more effectively. However, it must be acknowledged that members of the staff team demonstrate a sensitivity towards and an awareness of residents’ needs, that only comes from spending time with people and developing an understanding of their particular ways. Staff actively seek to support residents to make decisions and exercise choice as an integral part of their day-to-day interactions. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 16 Residents are able to take part in appropriate activities and to be a part of their community locally, but work needs to be done to develop opportunities further. Staff respect residents’ rights and work hard to promote and encourage independence and choice. EVIDENCE: Records show that residents are able to take part in a range of valued activities, both at home and out in the community. The organisation employs two people with specific responsibilities for supporting the care team in providing activity opportunities, but these members of staff do not work at weekends. Work needs to be undertaken to analyse comprehensively the opportunities currently available to people living in the house. Some work has been done on this, but this now needs to be developed further. Recording of activities undertaken should include some statements about the intended purpose (e.g. therapeutic, educational, developing or maintaining skills, just for fun – or any combination of these). This could be used positively to inform future care planning and support goal setting. It should also make Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 12 clear how choices have been offered, and how particular activities were chosen. Ways of taking this forward were discussed with the Manager, and this will be assessed more fully at the next inspection. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 & 19 Residents are given personal care and support in a respectful and friendly manner according to their requirements. There are unresolved issues about whether or not current bathing facilities fully meet people’s needs. Good progress has been made to ensure that residents’ health needs are now met appropriately. EVIDENCE: All five residents were seen during the course of the day. It was evident that the basic standard of physical care is high: all the residents were well dressed in their own individual style and well supported in their personal care. Staff members were observed to be warm and friendly, and delivered support in a polite and respectful manner. Residents and staff appear relaxed and comfortable in each other’s company. Staff are sensitive to people’s communication support needs and try hard to engage and offer choices appropriately. It is recommended that consideration be given to ways in which staff’s expertise might be further developed, so as to enhance communication opportunities for residents. This might involve seeking expert professional advice, and providing additional training opportunities for staff. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 14 Previous inspections have identified issues relating to the provision of specialist bathing facilities. Requirements have been made that these should be consistent with the levels of needs of the residents. These issues have not yet been fully resolved: they are addressed further in the “Environment” section of this report (Standard 27). Members of the staff team do everything they can in the current circumstances to respect residents’ rights and dignity. A number of requirements were also made at the last inspection in relation to meeting residents’ healthcare needs. It is clear that a good deal of work has gone on so that these matters might be appropriately addressed. Records relating to medical appointments have improved, Waterlow risk assessments, and manual handling risk assessments have now been put in place or reviewed as required. Monitoring of weight and of bowel care is now being effectively recorded, though guidance in care plans with respect to required follow-up action (re: - bowel care) is outstanding, as advice is currently being sought from the GP. A protocol for the epilepsy care of one resident has now been agreed with the prescribing doctor, and a signed copy is in place on the personal file. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 It is difficult to assess fully whether residents consider that their views are listened to and acted upon, but efforts are made to consult and to be aware of issues important to individual residents. The complaints procedure needs minor adjustments. Staff practice and the Organisation’s policies and procedures give residents protection from abuse, neglect and self-harm. EVIDENCE: At the time of the last inspection a requirement was made that the complaints procedure be amended, as it was considered that the wording suggested that the complainant had only three days in which to register any complaint. It should be acknowledged that the form of words used has other possible interpretations, and that the organisation did not intend to restrict individuals’ opportunities to make complaints. It is recommended that a slight adjustment be made to the sentence to indicate the desirability of making the complaint within three days of an incident, or as soon after as is practicable. Similarly, the period within which a complainant can appeal should be extended. The norm in such matters is generally 28 days. The communication needs of this particular group of residents mean that it is hard to assess fully if they consider that their views are listened to. However, staff try very hard to ensure that residents are as involved as much as possible, or as each person’s individual capabilities allow. A sample check of two residents’ financial records was undertaken. Money held balanced with the account, and receipts were available to verify expenditure. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 16 The Adult Protection procedure is in need of slight amendment; it must be made clear that any internal investigation by the organisation must be “put on hold” if the Police are involved, so as to avoid any risk of contamination of evidence. It is also recommended that the policy include a specific crossreference to the local multi-agency guidelines on the Protection of Vulnerable Adults. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27, 29 & 30 Natalie House provides its residents with a comfortable and safe home environment. There are unresolved issues concerning the suitability of current bathroom facilities and the provision of specialist equipment for some of the residents, though general provision is very good. The Home is kept clean and tidy, and good standards of hygiene maintained. EVIDENCE: The residents at Natalie House benefit from a home environment that is purpose-built. The house is comfortably furnished, decorated to a good standard, and well maintained. It was seen that jobs identified were put into the Home’s maintenance book, and generally dealt with in a reasonably short time. The kitchen has just undergone a major re-fit, with a small amount of redecoration and “making good” required to complete the job. Residents all have single bedrooms with en-suite facilities. Rooms are decorated and furnished in individual styles, and personal possessions and effects are much in evidence. A requirement from the last inspection that soft furnishings should be rendered flame-retardant has been dealt with and all items treated as appropriate. The house is kept clean and tidy, and good standards of hygiene maintained. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 18 As mentioned earlier in this report, there are matters outstanding with regard to the provision of specialist bathing facilities in the house. There is one bathroom. The bath, which has a spa facility, is at a fixed height and allows access from both sides. There is a health and safety issue for staff, who are obliged to bend down to support residents using the bath. There are insufficient facilities in the bathroom to enable one resident, who is unable to stand, to get dressed or undressed in there: this has to be done on the bed in her own room. She then has to be taken to and from the bathroom covered in towels. Her room is adjacent to the bathroom, and staff do all that they can to ensure that this is carried out sensitively and the resident’s dignity preserved. However, it is clear that these arrangements are not entirely satisfactory. Two other residents do not use their en-suite shower facilities either, so three of the current five residents rely on the bathroom for “all-over” washing. The Manager advised that advice had been sought from an occupational therapist, but no firm conclusions had yet been reached. A letter of serious concern with regard to these matters was sent to the provider following the last inspection, but no reply to this has been received since then. This issue needs to be resolved without further delay. The assessment and care plans for each individual’s bathing support needs must be reviewed immediately, and a detailed report submitted to CSCI. This should include specific details of any professional advice received from Occupational Therapists or Physiotherapists, and proposals for implementing this. Consideration must be given to the provision of appropriate facilities for changing, moving and handling each resident, and these details must also be included in the report. Given that the Home is currently registered to provide support for people with physical disabilities, it is of paramount importance that the facilities available within the Home reflect this appropriately. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 & 36 Recruitment policy and practice is appropriately robust and provide residents with the support and protection they require. An up to date training and development plan is required in order to assess accurately the training needs of the staff team, to enable them to support residents appropriately. Residents benefit from a staff team that is well supported and supervised. EVIDENCE: Records for two of the most recently appointed member of staff were examined and found to be in order. All documents required under the relevant regulations were in place on the personal files of the individuals concerned. Staff training is provided under a rolling programme, and there is a chart for this on the office wall, though this was not fully up to date. A requirement was made that the staff training and development assessment should be forwarded to CSCI. This should indicate training already completed by each member of staff, when refreshers or additional training courses are due, when training is actually scheduled, and who is to deliver it. Staff supervision records were seen to be generally up to required standards. Group meetings for staff also occur on a regular basis; a recommendation was made that recording for these meetings should be improved Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39 & 42 The management approach within the Home is transparent and inclusive. Work needs to be done to develop quality assurance and monitoring systems, to ensure that residents’ views are represented as fully as possible. General practice, policies and procedures promote the health and safety of residents in an effective manner. EVIDENCE: The Manager and staff team appear to have a genuine rapport and a good working relationship, and the style of management is open and inclusive. There is a need to develop systems for quality assurance and monitoring in the Home. One way of contributing to this has already been mentioned earlier in this report, with regard to analysing people’s activity opportunities. There is a huge challenge for the staff team and the Organisation to monitor the quality of the service on offer when the “consumers” are people with high support Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 21 needs and limited communication abilities. This is another reason for focussing on enhancing the expertise of the care team to communicate more effectively. This can only be of benefit to the residents and members of staff alike. A requirement was made at the last inspection that records of the visits required under Regulation 26 should be available in the Home. This remains outstanding, though entries in the visitor’s book indicate that the nominated person has visited regularly in the past three months. Fire safety records were fully assessed at the last inspection in March 2005 and found to be in order, as were electrical wiring and portable appliance testing certificates. However, the workplace fire risk assessment is still in need of review. The tail-lift on the Home’s vehicle, and the mobile hoists in the building have now been serviced. The fridge was inspected and the requirement that all opened food packages should be labelled with the date of opening has been met. The COSHH cupboard was seen to be appropriately secure. Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 1 x 1 3 Standard No 11 12 13 14 15 16 17 x 2 2 x x 3 x Standard No 31 32 33 34 35 36 Score x x x 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Natalie House Score 2 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 2 x x 3 x E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA 5 YA 6 Regulation 5 (1b-c) 15 (1-2) Requirement Residents contracts must be reviewed in accordance with Standard 5.2 Care plans should be developed so that they contain all information essential to provide individual support. Care plans should also include goals with measurable outcomes, and be reviewed at least every six months. Reviews should be recorded in writing, and indicate who takes part and how decisions are reached. Risk assessments should be cross-referenced with the care plan(s) to which they relate, and reviewed in conjunction with them (as at 2. above) Residents opportunities for activities must be properly evaluated as an integral part of their care plan reviews. This must include accurate recording of activities offered, declined and undertaken, both at home and in the community. It must also include information concerning the purpose of activities undertaken and demonstrate how choices have been made. Timescale for action 31.08.05 31.08.05 3. YA 9 13 (4a-c) 31.08.05 4. YA 12 16 (2m-n) 31.08.05 Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 24 5. YA 18 15 (1-2) 6. YA 19 12 (1-3) 7. YA 22 22 8. YA 23 13 (6) 9. YA 27 & 29 23 (2n) 10. YA 33 18 (1a) 11. YA 35 18 (1c) Ways of enhancing residents communication opportunities must be actively explored so as to improve levels of engagement and enhance consultation. Guidance must be obtained from the GP in respect of residents whose bowel care requires monitoring, and advice given included in individual care plans. The complaints procedure should be amended to indicate that complaints should be registered within 3 days, or as soon afterwards as is practicable. The appeal period should also be extended. The adult protection procedure should be amended to make it clear that any investigation must be suspended immediately if the Police are involved, so as to avoid any possible contamination of evidence. The procedure should also include a crossreference to the local multiagency guidelines on the Protection of Vulnerable Adults The bathing support needs of each person in the Home should be reviewed, and a report submitted to CSCI in accordance with guidance given in the main body of this report ( see Standard 27) A review of staffing levels must be completed to include support required at mealtimes and to undertake personal care routines, as well as the provision of appropriate activity opportunities in the evenings and at the weekend. Outstanding since 31.05.05 The training and development plan for staff must be submitted to CSCI. This should include details of training already 31.08.05 31.08.05 31.08.05 31.08.05 31.08.05 31.08.05 31.08.05 Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 25 12. YA 39 24 (1-3) 13. YA 40 13 (2) 14. YA 41 26 15. YA 42 23 (4a) completed by each staff member and indicate when refreshers or additional courses are required, when these are scheduled, and who is to deliver the training. The Organisation should develop and implement systems to monitor and evaluate the quality of the service offered in the Home, taking special account of the communication needs of the residents. The medication policy should be developed to give clear guidance on procedures when administering medication, and the action to be taken in the event of an administration error. Outstanding since 31.06.05. Reports of visits required under Regulation 26 must be available for inspection. Outstanding since 30.04.05 The workplace fire risk assessment must be reviewed and updated. Outstanding since 30.04.05 30.09.05 31.08.05 31.08.05 31.08.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA 6 YA 9 Good Practice Recommendations Residents communication guidelines should be placed in a prominent position on their care plans. Risk assessments should be indexed appropriately Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Natalie House E54_S16731_NatalieHse_V234468_230605 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!