CARE HOME ADULTS 18-65
Noire House 31 Abbotts Road Erdington Birmingham B24 8HE Lead Inspector
Joe OConnor Unannounced 4 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Noire House Address 31 Abbotts Road Erdington Birmingham B24 8HE 0121 382 0217 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) Robina Care Rosemarie Ann Fitzpatrick Care Home 4 Category(ies) of Younger Adults, Learning Disability [4] registration, with number of places Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Residents must be aged under 65. 2. The manager must obtain an NVQ Level 4 in Management or equivalent by December 2005. 3. That Mrs Rosie Fitzpatrick is also registered for The White House, 219 Green Lane, Wylde Green, Sutton Coldfield, Birmingham, B73 5LX with the condition that the responsible individual provides additional management support with a suitably qualified and competent deputy manager at both the White House and Noire House working at least 30 hours per week. Date of last inspection 9 March 2005 Brief Description of the Service: Noire House is a modern purpose built home at the end of Abbotts Road in Erdington. It provides accommodation to four people with learning disabilites. The house feels light and airy with a homely atmosphere. To the rear of the property is a large garden, which surrounds both sides of the premises and is laid to lawn. There is some off road parking. The ground floor of the premises consist of a large lounge, with a conservatory that is used as a dining room. There is also a large kitchen which is occasionally used as a second dining room. A toilet, separate laundry area and office is also located on the ground floor. There are four single bedrooms on the first floor, all of which are a good size and a bathroom with a shower. The service is well situated for local amenities such as Erdington, Star City and The Fort retail park. It is also close to bus routes for Birmingham City Centre. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day. The Inspector had the opportunity to talk to three service users although one did have limited verbal communication and could not totally convey his views on life in the home. Observations of interactions and support of staff were undertaken. The Inspector also had the opportunity to talk to the manager. Service users care plans and risk assessments were inspected. Staff training records was also examined and a number of health and safety records were also sampled. What the service does well:
Service users live in accommodation that is modern in comparison to the structure and external features of other properties in the neighbourhood, but that does not identify its purpose as a care home. Service users were observed to receive friendly and professional support from care staff. A comment received from one service user stated, “ I like living here and I can go to bed and get up when I want to”. Another service user commented how much she enjoyed her birthday party that had been arranged by staff. A third service user who has limited verbal communication put his thumbs up to indicate that he was happy in his accommodation. Service users appeared well cared for and dressed in clothing appropriate for the climate of the day. The majority of staff have completed the majority of training topics and future training had been planned for autism and makaton. Service users have the opportunity through the weekly meetings to communicate their wishes and feelings about the food provided and future activities. They have the opportunity to go out in the community such as the cinema at Star City, local pubs, shopping and horse riding. A number of service users are able to access activities with the local colleges and day services provided by the Local Authority. Service users are able to spend time as they please and no rigid rules and routines are present. It was good to see that service users birthdays are celebrated with family, friends and the other service users. One service user was pleased to show a photograph album of her recent birthday party that included a disco. There is a relaxed friendly atmosphere that appears to benefit service users. They have access to local healthcare professionals such as GP, dentist, optician, and chiropodist. Specialist support is available through the local Primary Care Learning Disability Trust. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better:
Service users meetings must state where any previous requests to participate in activities had been followed up. When dealing with service users personal allowances staff must provide two signatures on the individual expenditure records. A number of the organisations’ policies and procedures were in need of reviewing and updated to reflect current practice. These included procedures for adult protection, physical intervention and complaints. Medication management was found to require improvement. The manager must ensure that all medication including the amount and strength is recorded onto the Medicines Administration Records or MAR charts, as they are known.
Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 7 The service receives visits from a representative of the organisation who checks records and talks to service users and staff about the management of the service. It was noted that there had been no visits between April and June 2005. The reports available from previous visits do not provide enough detail from service users about what they thought of the service. Some improvements are required to the complaints procedure to ensure that it is accessible for service users with non verbal communication. Amendments are also required to the complaints procedure format for service users by Robinia Care Ltd. The requirement issued following a visit by the Environmental Health Officer, for new coloured chopping boards had not been addressed. Service users weight must be recorded every month and the manager must ensure that any reasons why service users weight had not been recorded are noted in their weight chart. While it was good to see that one member of staff had been registered for LDAF training it is still a requirement that all staff are registered for this. Service users contracts must include a breakdown of the fees covering their accommodation and any charges to be paid not covered by the fees. 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. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 8 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 Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 5 Service users have a Statement of Purpose and Service User Guide, which the manager is developing to make the documents more accessible for the current group of service users. Some improvements are required. The needs of service users are being met through the maintenance of detailed care records. Service users have a statement of terms and conditions that does not provide a breakdown of fees to be paid. Standard 2 not assessed, as there have been no new admissions to the service. EVIDENCE: Since the last inspection the organisation has provided a statement of purpose and service user guide, which the manager has been developing into more accessible documents through the use of pictures. This is to make it more individual to the service. Some improvements are required to ensure the documents state where the service does not meet the National Minimum Standards with regard to the physical environment. Each service user has had a new statement of terms and conditions but these do not provide information as to the breakdown of fees to be paid and any charges not covered by these. Service users needs were found to be met during this inspection. One service user who was able to speak about life in the home stated, “ I like living here”. Another service user stated that she enjoyed the soups made by a particular member of staff. Another service user who had very limited verbal
Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 10 communication put his thumbs up and nodded to indicate that he was happy where he was living and was looking forward to going out later in the day to the pub for a drink. Service users appeared well cared for and dressed in clothing that was appropriate to their age. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 11 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, 8, 9 Care plans provide detailed information of service users needs and how they should be met. Service users are encouraged to make decisions about their lives through the use of weekly meetings, with improvements required in ensuring service users requests for future activities have been addressed. Service users have risk assessments concerning limitations on their independence. EVIDENCE: Each service user has a care plan that covers all aspects of their daily living activities. The care plans also contained pen pictures of each service user. One stated that the service user was able to speak Punjabi while another stated that the service user was bale to choose the time when they wanted to go to bed and get up. Since the last inspection the manager and staff have been working with the service users to develop a “ This is Me” book that will provide service users a more person centred approach to planning their care. The books sampled contained photographs including and details of their likes and dislikes. One sampled stated that the service user likes to help with shopping and enjoys listening to Bhangra music. The care plans had been reviewed since the last inspection. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 12 Service users are encouraged to be independent and any limitations in the home are documented on individual risk assessments. There were risk assessments in place that referred to a requirement that one service user must not be alone to bathe due to their epilepsy. There were also risk assessments in place that covered service users being escorted in the community and the number of staff required to support them. Service users have meetings every Sunday and minutes for these are maintained. These involve service users in identifying their wishes with regard to any menu changes and activities. It was noted that some of the minutes had requests made by service users to pursue a particular activity but there was no confirmation at the next meeting whether service users wishes had been addressed. For example one service user had requested to bake cakes but there was no confirmation at the following week’s meeting whether this had been done. Observations at the time of this inspection found staff were encouraging service users to choose what they wanted to eat or where they wanted to go. Service users’ personal allowances were examined and there were records in place that showed monies coming in, what had been spent and for what purpose with a final balance total. Service users monies are held in their individual wallet and purses. There was evidence of receipts for items purchased but the manager must ensure there are two signatures in all transactions. There is information on service users’ care records to state that is acting on the behalf of service users with regard to their personal finances and benefits. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 15, 16, 17 Service users have access to leisure activities and also receive organised activities by other agencies. Service users maintain positive relationships with each other and staff. Service users routines are not subjected to any unnecessary restrictions subject to their individual risk assessments. Service users have access to nutritious and wholesome meals. EVIDENCE: Service users records contained information with regard to their activities during the day. A number of service users receive daytime services provided by the Local Authority. Daytime activities are also provided by the service including hydrotherapy horse riding, cinema, shopping and pub lunches. At the time of this inspection three service users were going out during the afternoon for a meal and see a film at Star City. One service user stated that she went a social club every Friday evening. Another service user goes to church every Sunday. The relationships between staff and service users were generally professional. Service users records confirmed where they had contacts with relatives. One service user was pleased to show a photograph album of her recent birthday
Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 14 party. There were photos of her relatives and friends including those from her daycentre and another home. It was evident that everyone had a great time and it was good to see the service users dressed really smart for the occasion. Another service user had also recently had a birthday party and there were photographs of family members who had travelled from Ireland. Staff commented that they were discussing with another service user’s family to arrange a birthday party with the addition of a Bhangra music DJ. The service user has home visits to his parents every weekend. Observations at the time of this inspection found that this is very much the service users’ own home with no unnecessary rules or routines. Service users have access to a range of nutritious meals and records are maintained of what service users have eaten. It was noted that one service user had guidelines in place developed by a Speech and Language Therapist, that highlighted the need for the service user to have soft moist food because of difficulties with swallowing. The food cupboards, refrigerator and freezer were well stocked. For those service users who have non verbal communication needs menu choices are ascertained through the use of a picture book with photos of meals including soups and puddings. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 15 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, 20 Service users receive flexible care and support to meet their individual requirements. Service users healthcare is appropriately arranged by staff, promoting and maintaining good health. Service users weight must be recorded regularly as part of maintaining their nutritional well being. Medication management needed improving so that service users good health is maintained. EVIDENCE: Care records sampled confirmed where service users had received support with their personal care. Each service user has gender care guidelines and one seen stated that the service user required assistance from a female member of staff. It was evident that any changes with regard to any changes in any service users health were followed. Detailed records are maintained where service users have received treatment form GP, Dentist, Optician and Chiropodist. There are good relationships with specialist services such as Consultant Psychiatrist, Psychologist and Speech and Language Therapist provided by the Primary Care Learning Disability Trust. Service users weight is monitored although a sample of care records found that this was not consistently done every month. The manager must ensure that any reasons why service users have not been weighed must be documented. Each service user was found to have a manual handling assessment that had been reviewed since the last inspection.
Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 16 Medication management was good but required some improvement. An examination of the Medicines Administration Records (MAR charts) found that a hand written entry for Chlorpromazine and Lactulose solution medication had not been signed on the MAR chart to confirm the quantity and strength of medication received. The manager had addressed a number of requirements since the last inspection including a revised medication procedure and an up to date procedure for the use of homely remedies. Staff had received accredited medication training since the last inspection. A sample of service users records found that service users had received medication reviews. There were protocols in place for the use of PRN or when required medication as it is known. While the manager has developed her own medication policy and procedure for the management of medicines, the organisations main policy and procedure in this area does not fully reflect current practice. It does not state that any medication errors must be reported to the CSCI without delay. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 17 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 Service users have access to a complaints procedure that is available in a suitable pictorial format with some improvements required. Service users welfare is protected with staff receiving training in the protection of vulnerable adults. The organisation’s policy and procedure with regard to adult protection requires amending to reflect current practice. EVIDENCE: Neither the CSCI nor the service has received any complaints since the last inspection. It was noted that there is a complaints procedure on display in the hallway and office. This was found to combine the use of illustrations and the use of a photo of the service manager for the organisation. However, some improvements are required so that the complaints procedure is more accessible for those with non verbal communication and have difficulty with reading. It must also state that service users can contact the CSCI at anytime during the complaints process. Assurances must be given that no one will be victimised as a result of making a complaint. Staff training records showed that staff had completed training in the protection of vulnerable adults with further training being provided throughout the year. The manager has made arrangements for updated training in areas such as physical intervention and challenging behaviour. The manager has an up to date copy of the Multi Agency Guidelines published by Birmingham Social Care & Health. It was noted that that the organisation’s policy and procedures for adult protection and physical intervention had not been amended as required from the previous inspection. It was also noted that there was no policy and procedure in place for whistleblowing.
Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 18 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, 30 The premises are maintained to an acceptable standard and provide a clean safe environment for service users. EVIDENCE: The premises was found to be clean, tidy and smelled fresh. Service users were observed to move freely around the premises without any hazards. A requirement from the previous inspection for the hallway floor to be repaired had been addressed. No full tour of the premises was undertaken but the laundry area was viewed and this was found to be clean and tidy. It has a washing machine that has a sluice programme. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 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) 33, 35, 36 Staffing levels provide service users with a continuity of care that meets their needs. The organisation provides training to all staff employed to enhance their development. Staff receive supervision but these need to be more frequent. EVIDENCE: The manager provided a copy of the training plan for the next twelve months and it was evident that staff had completed training in areas such as first aid, manual handling, and infection. Future training that has been arranged includes fire safety, food hygiene, autism and communicating in makaton. One member was positive as to the quality of the training provided by the organisation. The manager stated that so far only one member of staff had been registered for training towards the Learning Award Framework or LDAF, as it is known since the last inspection. A requirement from the previous inspection was for all staff to be enrolled for LDAF training. Further examination of staff records found that staff were receiving supervision but not every two months. A sample of the staffing rota indicated that generally the current levels of staffing were meeting the needs of service users. Staffing levels have remained stable since the last inspection. It was noted that the manager had completed risk assessments for those staff that regularly work long shifts, a requirement from the previous inspection.
Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 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) 37, 38, 39, 41, 42 Service users live in a home that is run by a competent manager. There is an open, relaxed and friendly atmosphere that benefits service users and staff. The organisation must be more frequent in ensuring service users views about the service are heard. Service users health and safety is promoted and maintained. The records were generally up to date and secure protecting the interests of service users. Standard 40 not assessed but the outstanding requirement from the previous inspection has been brought forward. EVIDENCE: The manager demonstrated her knowledge and understanding of service users needs. She has worked hard in making a number of improvements with regard to making the records more streamlined and ensuring service users’ records are individually personalised. The manager has almost completed qualification to NVQ Level 4 in Management. In discussion with the manager it was revealed that the organisation have appointed a full time manager for the service after
Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 21 it had failed to recruit a deputy manager. No written confirmation had been received at the time of writing this report. The manager felt this was a better outcome for the service users and staff, as she could not provide a total commitment to the service while being the Registered Manager for another service. The atmosphere was found to be relaxed and friendly which benefits service users. In discussion with the manager she felt there was had been a lot of improvement with the commitment of staff to ensure service users had wider opportunities to go out. There were reports on file to confirm that a representative from the organisation had visited the premises to ascertain service users and staff views as to the management of the service. It was noted that the visits had not occurred every month and there was little in the way of content from service users and improvement is required ensuring service users views are heard in full. The records were found to be generally up to date and held in a locked facility. The manager has included photographs for the service users’ care plans Records with regard to health and safety were found to be satisfactory. Documented evidence was in place to confirm that the fire alarms were being tested on a weekly basis and the emergency lighting every month. There was a risk assessment in place for the premises. A fire drill had occurred prior to this inspection. Environmental Health had visited the service since the last inspection and the only requirement issued was for the replacement of the coloured chopping boards. The manager stated that so far this requirement had not been addressed. It was good to see from examining the accident book there were no significant numbers of accidents since the last inspection. The daily occurrence book had been updated, which was a requirement from the previous inspection. Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 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 2 x 3 x 2 Standard No 22 23
ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 2 2 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Noire House Score 2 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 3 2 x E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 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. Standard 1 Regulation 4(1) 5(1) Schedule 1 Requirement The Registered Person must ensure the Statement of Purpose and Service User Guide clearly states where the service does not meet the NMS with regard to the physical environment. Copies to be forwarded to the CSCI. The Registered Person must ensure that the service users statement of terms and conditions provides a breakdown of the fees and any charges not covered by these. The Registered Person must ensure there are two signatures when administering service users personal allowances. The Registered Person must ensure that the minutes for service users meetings state whether any previous requests for activities from service users had been addressed. The Registered Person must ensure service users are weighed every month. Where service users weight has not taken place, then the reasons for this must be documented. The Registered Person must ensure the quantities of all Timescale for action 4 October 2005 2. 5 5(2)(b) 4 October 2005 3. 7 13(6) 4 September 2005 4 October 2005 4. 8 12(3) 5. 18 12(1)(a) (b) 4 October 2005 6. 20 13(2) 4 September
Page 24 Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 7. 20 13(2) 8. 22 22(1) 9. 23 13(6) 10. 23 13(6) 11. 23 13(6) 12. 36 18(2) medicines received into the home must be recorded to enable accurate audits to be undertaken and to demonstrate staff competence in medicine management. The organisations policy and procedure with regard to medication must be reviewed and amended to reflect current practice. The Registered Person must ensure that the complaints procedure is amended to state that the CSCI can be contacted at anytime during the complaints process and assurances will be given that no will be victimised a result of making a complaint. The procedure must be available in a more accessible format for service users. The Registered Person must ensure that the policy and procedure for physical intervention is amended that the CSCI must be notified of any use of physical intervention has occurred. Outstanding Requirement. Timescale 9 June 2005 not met The Registered Person must ensure that the adult protection policy and procedure must state clearly that any incidents of abuse must be reported to the CSCI without delay via Regulation 37 notification. Outstanding Requirement. Timescale 9 June 2005 not met. The Registered Person must ensure there is a policy and procedure in place for whistleblowing. Outstanding Requirement. Timescale 9 June 2005 not met. The Registered Person must ensure staff supervision occurs 2005 4 October 2005 4 October 2005 4 October 2005 4 October 2005 4 October 2005 4 October 2005
Page 25 Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 every two months. 13. 39 26(1) The Registered Person must ensure that visits undertaken by a representative of the organisation must take place on a monthly basis. The reports for these must provide more detail in comments from service users and staff. The Registered Person must ensure that it reviews its current policies and procedures to ensure they meet the National Minimum Standards and reflect current practice. Some have not been reviewed since 2000 & 2001. Outstanding Requirement. Timescale 9 July 2005 not met. The Registered Person must ensure that requirements issued by Environmental Health is addressed. The Registered Person must ensure that all staff are registered for training towards the Learning Disability Award Framework programme. Outstanding Requirement. Timescale 9 June 2005 not met 4 September 2005 14. 40 17(2) NMS Appendix 2 4 October 2005 15. 42 13(3)(4) 4 September 2005 4 October 2005 16. 35 18(1)(c) (i) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Noire House E54 S64613 Noire House V242101 040805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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