Inspection on 12/05/05 for The Old Coach House

This inspection was carried out on 12th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 40 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Coach House 03/03/08

The Old Coach House 05/01/07

The Old Coach House 24/11/05

The Old Coach House 10/02/05

The Old Coach House 22/09/04

The Old Coach House 29/03/04

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 Old Coach House 20 Wychall Park Grove Kings Norton Birmingham B38 8AQ Lead Inspector Donna Ahern Unannounced 12 May 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. Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Old Coach House Address 20 Wychall Park Grove Kings Norton Birmingham B18 8AQ 0121 459 1433 0121 451 2779 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) Sense West Vacant CRH 5 Category(ies) of Learning Disability (5) registration, with number Sensory Impairment (5) of places Old Coach House E54 S16807 Old Coach House V226991 120505 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 10 February 2005 Brief Description of the Service: The Old Coach House is a spacious, detached house along a drive between houses in a residential area of Kings Norton. There are shops nearby and reasonable access to public transport. Accommodation is provided for up to five adults with dual sensory impairment and additional learning disabilities. All the bedrooms are single. Two of the bedrooms are on the ground floor and three are on the first floor. There is no lift. There are two bathrooms one on the ground floor and one on the first floor. Both are domestic in style and have no aids or adaptations. There are two additional toilets on the ground floor. An office is available on the first floor of the house. The home has a large lounge with a dining area. The garage has been converted into additional communal space for the deaf/blind people. The premises are light and airy. There is a private garden to the rear of the property. This has raised flowerbeds and a patio. Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. Conversations with the deaf/blind people were limited due to their complex needs and limited verbal communication abilities. However, the inspector spent time with all five deaf/blind people observing care practices, interactions and support from staff. A tour of the building was made. Care plans and risk assessments were inspected. Staff training and recruitment procedures were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the acting manager, and informally to two of the support workers. What the service does well: What has improved since the last inspection? What they could do better: Not much progress had been made on previously raised requirements. A lot of work must be done to make it a safe and comfortable home for the people who live at The Old Coach House. The home must improve the care plans that they have on each deaf/blind person. These tell the staff how to support each person. They must be clear about what help and support each deaf/blind person needs and what the staff must do to support the individual. These must be kept up to date. Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 6 The support the deaf/blind person requires from staff at mealtime must be documented on the care plan and kept up to date. Staff must make sure that they are present to help and support each deaf/blind person whilst they are eating. The home must improve the range of activities that all deaf/blind people can take part in. They must record what each person has done and keep records of what they have enjoyed. The deaf/blind people pay a lot of money every week towards the minibus. Only one member of staff can drive the minibus. This is not a fair way to charge individuals and must be looked at by the people who own the home. The home must provide a holiday or a short break for all deaf/blind people. The home must improve the way that the deaf/blind persons health needs are recorded and followed up. The home must start to do Health Action plans with each individual. The home must improve the records it keeps on some of the Health and Safety checks. It must make sure that the home is kept clean and staff must not leave things that could be dangerous for someone who has vision problems. They must make sure the house is safe for the deaf/blind person. If something gets broke they must repair it or make it safe. The home must keep in the house information about the agency staff that helps out in the home. Staff must do more training so that they have the skills and knowledge to do their job and support the deaf/blind people. The home must improve how it says it will help the deaf/blind person reduce some of the risks that they may face in the home or when they go out on an activity. 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. Old Coach House E54 S16807 Old Coach House V226991 120505 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 Old Coach House E54 S16807 Old Coach House V226991 120505 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) Not assessed at this inspection. EVIDENCE: Old Coach House E54 S16807 Old Coach House V226991 120505 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 Care plans and risk assessments required development and have not been kept under review. These shortfalls are of concern as they have the potential to cause inconsistencies in the care given to the deaf/blind person and place them at risk. EVIDENCE: Three care plans were examined. The care plans contained a lot of information however; they had not been kept under review. Care routines and guidelines were dated March 2004. Many sections of the care plan had a date for review however this date had lapsed with no evidence that a review had taken place. Mealtime guidelines were due to be reviewed for one person in February 2005. There was no evidence that this had taken place. There was no evidence of how the “goal” and “aspiration” section was put into practice for each deaf/blind person. The schedule of activities was not reflected in daily practice. Daily records were poor and there was no evidence of how choices are offered. There was no detail of the deaf/blind persons response to care given. The activity sections on the daily record sheets were frequently not completed. A number of risk assessments were examined. These required further development. Risk assessments required implementing in relevant areas to ensure that the risks people are exposed to are assessed and planned for. Risk Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 10 assessments were required for the support received during the night from the waking night staff. The outcome of the risk assessment must inform the guidelines that are in place. The risk assessment must be clear and specific about the risk to the deaf/blind person and the action required by support staff. The risk assessments must be kept under review. Some risk assessments had been reviewed however; there was no evidence as to how the review was undertaken. Risk assessments for individuals who have epilepsy required review and development. The risk assessment must cross reference to the deaf/blind persons care plan and any relevant policies and procedures. Old Coach House E54 S16807 Old Coach House V226991 120505 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, and 14 The level of activity available to the deaf/blind person fails to provide fulfilling lifestyles. EVIDENCE: The care plans contained a “Schedule of activity”. When these were assessed they did not reflect what had taken place or what had been made available to individuals. The schedules included Worcester Sensory and swimming the acting manager said these activities were not currently provided. As previously highlighted recordings in the daily records were poor. Some recordings stated “went out” there was no details of where too, or the persons response to the activity. Of the recordings sampled several stated, “Sat in garden” “ sat in lounge” “walked to the end of the drive”. However one of the deaf/blind people attends a weekly music and I.T session and one attends a day centre three days per week. The staff and acting manager explained that there was one staff member who can drive the minibus and that this had had an impact on the range of opportunities available to the deaf/blind people. (This staff member is due to leave in June 2005) Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 12 The deaf/blind people contribute a set monthly amount from their mobility allowance to the running costs of the minibus. In light of the lack of drivers and use of the minibus these arrangements are not acceptable and must be reviewed. The deaf/blind people must be offered value for money and an equitable system. The previous report raised concern about the lack of holiday opportunities available to individuals. No progress had been made on this matter. The acting manager said that some staff were considering organising some day trips out in the summer. As raised in the previous report the home was asked to rectify this matter as high priority and notify CSCI of the outcome. A full mealtime was not observed, however, one person was eating lunch in the garden no one was supervising them. This matter was brought to the attention of the acting manager who instructed a staff member to sit with the person. The home must ensure that the deaf/blind people receive the proper care and supervision at mealtimes. Mealtime guidelines on care plans required review. Old Coach House E54 S16807 Old Coach House V226991 120505 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 and 20 Further development of the homes personal and healthcare recording and monitoring systems were required so that the home can evidence that the deaf/blind person’s needs are properly monitored and kept under review. EVIDENCE: The deaf/blind persons personal care routines required updating and review. The acting manager stated that the ground floor bathroom is to be refurbished so that it is more accessible for the one person who accesses the facility. It was advised that this must be done in conjunction with an Occupational Therapy assessment. CSCI must be kept informed of the outcome. It was difficult to track health input, monitoring and outcomes for residents. Health care information was kept in the care plan and there was also a separate health file containing the five-deaf/blind peoples health appointment details. The current system must be reviewed. Health Action plans must be commenced for all deaf/blind people as raised in the previous inspection report. Sampling of health records indicated that people are not weighed on a regular basis. Records indicated that they were weighed over nine months ago. The guidelines in place for the person with epilepsy required review and there must be evidence that their epilepsy is formally reviewed by a health professional. Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 14 The home had approached a local college so that staff could receive the required accredited medication training however; there was a waiting list. The acting manager stated that the home was exploring other options. The medication storage cabinet required cleaning and a loose tablet was found on the bottom of the cabinet. Prescribed cream in use was out of date. Creams must be dated when opened. Sample signatures required updating for staff who administers medication. Old Coach House E54 S16807 Old Coach House V226991 120505 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 and 23 Some development to both the Adult protection Policy and the Complaints policy was required to ensure that individuals are fully safeguarded. EVIDENCE: The homes complaints log indicated that no complaints had been received by the home. CSCI were formally notified of an internal investigation in the home. The outcome lead to the organisation taking disciplinary action against staff. The staff concerned no longer work in the home. The deaf/blind people due to their complex needs are not able to make a complaint and are reliant on staff, relatives or an advocate to act on their behalf. CSCI had investigated no complaints from service users or any other source in respect of this home. The organisation Sense had produced a new policy referred to as ‘issues policy’. This was assessed as meeting the required standard at previous inspections. It was advised that the home makes it explicit the different formats that the complaint procedure can be produced in. As already highlighted in this report the organisation must review its arrangements for charging the deaf/blind people for the use of the minibus, which they have limited use of due to the lack of drivers. The deaf/blind people must be offered value for money and an equitable system. Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 16 The staff records for the four staff on duty were examined. Two staff were permanent employees and two were agency staff. No records were available for the agency staff and CRB details were not available for Sense employed staff. As detailed in the staffing section of the report this was not acceptable and of concern an immediate requirement to address this matter was raised at the time of the inspection. The flow cart and contact details on the adult protection procedure required completion and must be on display. Old Coach House E54 S16807 Old Coach House V226991 120505 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) 24,25,26,27,and 30 Several routine maintenance matters were of concern and meant that the deaf/blind people were not provided with a safe environment. EVIDENCE: The home was comfortable and domestic in style. The home had recently converted a garage into additional communal space. The home does not have a lift and would not be suitable for a person who uses a wheelchair. There are steps up to the front of the home, however a side entrance provides level access to the rear of the home. Within the house two bedrooms are on the ground floor one of which has a step up to it. The two bathromms, one on each floor, are domestic in style and had no specialist lifting equipment. One bathroom is to be refurbished so that it meets the needs of the one person with some limited mobility. Several routine maintenance matters were highlighted and raised concern regarding the general safety of the premises and upkeep of the house. This is even more concerning considering the needs of the residents and their vision impairment residents are dependent on staff to maintain an environment that is safe. Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 18 The garden shed was used for excess paper work storage, it was not secured and also had COSHH (Control of substances hazardous to health) items stored. An immediate requirement to remove the hazard and secure the area was made at the time of the inspection. The garden area outside the kitchen door, which was reported to be the designated smoking area, had numerous discarded cigarette ends and a mop thrown on the floor. The kitchen floor was dirty, particularly in the corners where the flooring meets the kitchen cupboards. The ground floor toilet had an offensive odour and required refurbishment. The bathroom on the first floor had a broken shower rail and the shower curtain was ripped and trailing on the floor. The acting manager stated that it had been in this condition since April 2005. COSHH items were in the bathroom cupboard, which was not locked. There was no light shade in the bathroom. The lounge carpet required cleaning. Additional dining room chairs were required. There were only five chairs available so residents and staff could not sit down together at meal times. All five residents have a single bedroom with a wash hand basin. All bedrooms were inspected. Bedroom (k) was bare in appearance, the tap on the wash hand basin was damaged there was no plug in the sink and the blinds on the window were broken. In bedroom (P) the wash hand basin was boxed in, the previous inspection report required that the home should of consulted with CSCI on this matter and to undertake a risk assessment as a priority to evidence that it is the most appropriate way to manage the risk, there was no evidence that this had been actioned. In bedroom (C) the water to the wash hand basin had been disconnected due to a risk of the deaf/blind person flooding the bedroom. As stated above the home must evidence that this is the best way to manage the situation and demonstrate that other options have been explored, for instance press down taps could be installed. The previous report required the home to have an accessible call system in the bathroom. This remained outstanding. The acting manager stated that the home is in the process of ordering a system that should be fitted by the end of May 2005. It was also raised in the previous inspection report that each person should be able to access the radiator thermostatic controls on the radiators in their room. The action plan received from the manager who has now left the home stated that all radiators now have access to thermostatic controls. These were examined in the presence of the acting manager and were only available in the bedroom of the person who had recently moved into the home. This required attention. Old Coach House E54 S16807 Old Coach House V226991 120505 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) 33,34 and 35 Current staffing arrangements are at times failing to meet the needs of the deaf/blind person. The homes recruitment practices are failing to safeguard individuals. EVIDENCE: The home had three vacant posts for support workers and another staff member was due to leave in June 2005. This equates to a staff vacancy level of 40 . In addition to this the registered manager and deputy posts are vacant. Minimum staffing levels are three per shift for three days and on four days a week when one of the deaf/blind people is not at the day centre an additional staff member is on duty for eight hours. At night there was one waking night member of staff on duty with back up from a person on call (off the premises) if required. The staff files for the four staff on duty were examined. Two staff was permanent employees and two were agency staff. No details of training/experience or the CRB number and date of the check were available for the agency staff. CRB details were not available for Sense employed staff. This was not acceptable and of concern an immediate requirement to address these matters was raised at the time of the inspection. Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 20 The staff files required organising so that information could be easily accessed. The training record on staff’s personal file’s had not been updated and the training matrix examined indicated that staff required updates in all mandatory areas. Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 21 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 and 42 The home had not been adequately managed. The health, safety and welfare of the deaf/blind person had not been promoted and protected. EVIDENCE: The manager left in April 2005. A temporary manager was in place until a newly appointed manager takes up post in June 2005. The organisation must forward an application to register the new manager. All the evidence available at the time of the inspection indicated that the home had been in decline for a period of time. Required records had not been kept up to date. Routine maintenance matters had not been actioned. The emergency lights tests were two months over due. The weekly tests of the fire alarm system were six weeks over due. A fire drill was four months over due. The work place Fire Risk Assessment required review. The COSHH file required updating and review. Care plans and risk assessments had not been reviewed and required considerable development. Incidents requiring Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 22 notification had not been reported via a regulation 37 to CSCI, for instance one of the deaf/blind people had been admitted to hospital on the 11/3/05 and this had not been logged and CSCI had not been notified. As highlighted in this report staff training in mandatory areas had not been kept up to date and this required immediate attention. A significant amount of concerns regarding the general up keep and safety of the building were identified and raised concern regarding the homes compliance with relevant Health and Safety legislation. Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 23 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 x x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 1 1 x 2 2 Standard No 11 12 13 14 15 16 17 x 1 1 1 x x 1 Standard No 31 32 33 34 35 36 Score x x 2 2 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Old Coach House Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score x x x x 1 1 x E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 24 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 YA6 Regulation 15 (1) (2) Requirement The home must ensure that each deaf/blind person has a up to date service user plan. These must be reviewed at least six monthly. Guidelines must be reviewed. Timescale for action 15/8/05 2. 3. 4. YA6 YA7 YA9 15 (1) (2) 12 (2) 15/8/05 31/5/05 12/6/05 5. 6. YA9 YA9 7. YA12 8. YA13 Daily records must include individuals response to care and how choices have been made. 13 (4) Risk assessments must be (a,b c) further developed. There must be evidence of how they have been reviewed. 13 (4) (c ) The Risk assessment for the person with epilepsy required development/ review. 13 (4) Risk assessments must cross (a,b c) reference to the care plan and any relevent policies and procedures. 16 (2) The deaf/blind person must be offered a choice of activities.The range and choice of activites must be kept under review 12 (1) (b) The home must be able to evidence how they have supported the deaf/blind person to become part of and participate in the local community in accordance with their assessed needs and care E54 S16807 Old Coach House V226991 120505 Stage 4.doc 12/6/05 30/6/05 30/6/05 Old Coach House Version 1.30 Page 25 9. YA14 10. YA17 11. 12. 13. YA17 YA18 YA18 14. YA19 15. YA19 16. 17. YA20 YA20 18. YA23 plan. Opportunites must not be restriced because of transport issues. 16 (m) The deaf/blind person must have the opportunity to go on holiday. opportunities must not be restricted because of staff reluctance to go. 12 (1) The home must ensure that the (a,b) deaf/blind person receives the proper care and supervision at meal times. 15 (1) Meal time guidelines must be reviewed. 15 (1) The deaf/blind persons personal routines required review. 14 (2) An occupational Therapy assessment of the bathroom on the ground floor was required.CSCI must be informed of the outcome. 12 (1) (2) The home must review the monitoring of the deaf/blind persons health care. Health Action Plans must be implemented for all deaf/blind people. 12 (1) (2) The guidelines in place for the deaf/blind people with epilepsy required review and there must be evidence that their epilepsy is formally reviewed by a health professional. 18 (1) (c ) Staff must receive medication training that is accredited (previous requirement 31.12.04) 13 (2) Creams must be dated when opened. Sample signatures required updating for staff who administer medication.The medication cupboard required cleaning. One tablet required safe disposal. 13 (6) The organisation must review its arrangements for charging for the use of the minibus, which they have, limited use of due to the lack of drivers. Residents E54 S16807 Old Coach House V226991 120505 Stage 4.doc 31/8/05 13/5/05 31/5/05 15/8/05 31/8/05 31/7/05 30/6/05 31/8/05 15/5/05 31/7/05 Old Coach House Version 1.30 Page 26 19. YA24 20. 21. YA24 YA26 22. YA26 23. YA26 24. YA26 23 (2) (p) 25. YA27 23 (2) (b) 26. 27. 28. YA27 YA27 YA29 23 (2) (p) 23 (2) (b) 23 (2 ) (n) must be offered value for money and an equitable system. The garden shed must be secured. COSHH items stored in this area must be made safe and items that present a hazard to residents removed. The lounge carpet required cleaning. Bedroom (k) was bare in appearance, the tap on the wash hand basin was damaged there was no plug in the sink and the blinds on the window were broken and required repairing. Bedroom (P) the wash hand basin was boxed in the home should of consulted with CSCI on this matter the home must undertake a risk assessment as a priority to evidence that it is the most appropriate way to manage the risk. (previous requirement 11/5/05 0 Bedroom (C ) the water to the wash hand basin had been disconnected. The home must evidence that this is the best way to manage the situation and demonstrate that other options have been explored. The deaf/blind person must be able to control the radiators in their room. (previous requirement 31/12/04 ) The bathroom on the first floor had a broken shower rail and the shower curtain was ripped and trailing on the floor this required immediate attention The bathroom required a light shade to be fitted to the bare bulb. The ground floor toilet had a bad odour and required refurbishment. The home must have a accessiable call system. 21/5/05 30/6/05 30/6/05 12/6/05 12/6/05 30/6/05 13/5/05 31/5/05 31/7/05 31/5/05 Page 27 Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. YA30 YA33 YA34 YA35 YA35 YA41 YA42 YA42 YA42 YA42 YA42 YA42 23 (2) (b) 18 (1) (a) 7,9,19 schedule 2 and 4 18 (1) (c ) 18 (1) (c ) 37 (1) 23 (4) (c ) (v) 23 (4) (c ) (v) 23 (4) (e) 23 (4) (previous requirement. (previous requirment 31/12/04) The kitchen floor required cleaning/ resealing. The home must appoint to vacant posts. The home must have the required staff records available in the home Staff must receive training in all mandatory areas. A training plan must be forwarded to CSCI. Training records must be up dated and must include date duration and training provider. Notifiable occurrence must be reported to CSCI. The emergency lights must be tested monthly with a record of the test kept in the home . The fire alarm must be tested weekly with a record kept in the home A fire drill was required. 12/6/05 31/8/05 31/5/05 31/7/05 31/7/05 12/5/05 14/5/05 14/5/05 31/5/05 31/5/05 31/5/05 30/6/05 The Work place Fire Risk Assessment required review. 13 (4) The COSHH file required updating and reiew. 18 (1) (c ) Staff training in fire safety matters was required. 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 Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 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 Old Coach House E54 S16807 Old Coach House V226991 120505 Stage 4.doc Version 1.30 Page 29 - 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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