Inspection on 18/10/05 for 339 Pershore Road

This inspection was carried out on 18th October 2005.

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

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

Other inspections for this house

339 Pershore Road 18/08/07

339 Pershore Road 25/01/07

339 Pershore Road 19/04/05

339 Pershore Road 22/09/04

339 Pershore Road 18/05/04

339 Pershore Road 12/02/04

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

CARE HOME ADULTS 18-65 Pershore Rd (339) Edgbaston Birmingham B5 7RY Lead Inspector Kerry Coulter Announced 18 October 2005 th 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. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pershore Rd (339) Address Edgbaston Birmingham B5 7RY 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) Category(ies) of registration, with number of places 0121 472 0224 0121 4141534 Optimum Care Services Ms Desmin Hazle Care Home 6 6 LD Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. 2. That Desmin Hazle completes the registered Managers Award/ NVQ 4 in Care by 2005.. 3. The Home can continue to accommodate one named service user over 65 with a learning disability.. 4. That 339 Pershore Road apply for a variation on behalf of future service users who reach the age of 65.. 5. That details regarding how the specific care and social needs of people over 65 will be met must be included in the service user plan.. 6. Future admissions, and the statement of purpose be amended to reflect the age of service users accommodated.. Date of last inspection 19/4/05 Brief Description of the Service: 339 Pershore Road is a detached building situated on a main road that is on a bus route and fairly close to the centre of Birmingham. Accommodation for service users is provided in two single bedrooms on the ground floor and four single bedrooms on the first floor. All have wash hand basins and most have been personalised to reflect the individual tastes of service users. The home has a large fitted kitchen, a dining room, lounge, small laundry and a bathroom and shower room. The front of the house has a driveway that provides parking for several cars. The rear garden is large in size and has a patio area. There are shops within walking distance of the home and Cannon Hill Park and the MAC centre are nearby. The home is registered to provide personal care and accommodation for up to six adults who have a learning disability. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this announced inspection over five hours. This was the second of the statutory inspections for this home for 2005/2006, to get a full picture of this home this report should be read in conjunction with the report of April 2005. The Inspector was pleased to meet with most of the service users that live at the home during the inspection, the staff on duty and Manager. The Inspector looked at all the communal areas of the premises, and most bedrooms. The Inspector spent time talking to service users and observing the support and interaction between them and the staff. The Inspector looked at the records of care and care plans for three of the people who live in the home. Other records including fire safety records, rotas, staff supervision and training were also inspected. Information was provided by the Manager on the CSCI pre inspection questionnaire. One comment card was received from a relative of a service user. What the service does well: Service users have a planned timetable for attendance at activities that includes attending college courses, progressive mobility, music, church activities and the Midland Art Centre. Community facilities are regularly accessed to include the local shopping centre and pubs. It is commendable that the home has a very stable staff team with no use of agency staff. Staff give support with warmth, friendliness and patience and treat people respectfully. Staff at the home undertake training on a regular basis. Meals served at the home are at flexible times with a choice of food available depending on the personal preferences of service users. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 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 Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 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) 1 and 2 The Statement of Purpose and Service User Guide provide prospective service users with relevant information about the home to enable them to make a choice about if they want to live there. Written procedures ensure that assessment of new service users will be completed prior to admission to ensure the home is suitable for their needs. EVIDENCE: The Home has a Statement of Purpose and accompanying Service User Guide. This was found to meet the required standard. The service user guide was available in a picture format. Consideration could also be given to the use of video or audio as suitable to individual need. No service users have recently moved into the home. The home has a referral and admission policy in place that details that no admissions will be made to the home without a full assessment. Trial periods are offered on a three month basis. It is recommended that the policy is expanded to include how the views of current service users will be taken into account before a prospective service user moves in to the home. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 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 and 9 There is a clear and consistent care planning system in place to provide staff with information they need to meet service user needs. EVIDENCE: The care plans for three service users were sampled. Plans sampled were up to date with evidence of recent review and clearly identified the support required from staff. These included mobility, social and leisure, behaviour, daily living skills, family contact, communication, choice, privacy, dignity, rights, independence, fulfilment, health and self-care. Monthly evaluations by the key worker were being documented. As recommended at the last inspection a system of annual review meetings has been introduced, minutes of these planning meetings were available. It is positive that attempts to make the care plan accessible to service users had been made with the use of pictures and photographs incorporated into the plan. One file sampled contained guidance about strategies to manage the challenging behaviour of one individual. Care plans sampled cross-referenced to risk assessments so that the reader is naturally directed from one to the other. Service users are supported to take risks as part of an independent lifestyle. Risk assessments for service users were sampled and observed to be up to date with evidence of evaluation. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 10 Where changes had occurred such as one service user acquiring a walking aid then a new assessment had been completed. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 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, 14, 15, 16 and 17 Arrangements are in place so that service users experience a meaningful lifestyle. Service users are offered a healthy diet and enjoy their meals. EVIDENCE: Service users have a planned timetable for attendance at activities that includes attending college courses, progressive mobility, music, church activities and the Midland Art Centre. Community facilities are regularly accessed to include the local shopping centre and pubs. The home has in the last few months lost the facility of having a vehicle due to it being stolen. Records and discussions with staff indicate that the use of taxis and buses has not meant that service users have missed out on activities. Discussion with the Manager indicates that the home is hoping to get a replacement vehicle. Since the last inspection the Manager has introduced an activity monitoring sheet, this enable the reader at a glance to see the number of activities attended over a month period and records why any planned activities has not taken place. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 12 All service users have had the opportunity of an annual holiday. One service user went to Centre Parks with a service user from another home. The daily records of three service users indicated regular participation in leisure activities such as reading magazines, shopping, walks, football, visits to parks and the cinema. During the inspection one service user was provided with pens and paper by a member of staff when he indicated he wanted to do some drawing. Service users are encouraged by staff to maintain family links and friendships. The home has a visitors’ book in place where visitors to the home sign in and out. Information regarding visiting times was observed to be on display in the home. A visitor’s information folder is available in the reception hallway. The folder contains a variety of information including the inspection reports for the home, service user guide, and complaints procedure and visitor comment cards. One comment card from a service user’s relative was received by the CSCI, this did not raise any areas of concern. Service users were observed to participate in the daily routines of the home, this included participation in housekeeping tasks such as helping clear the table after a meal. Staff were observed to interact well with service users on an adult-to-adult basis, and are guided by their individual needs. Before entering a service users bedroom, staff were observed to knock on the door. An indication by one service user that he did not wish the Inspector to go into his room was respected by staff. The Inspector had the opportunity to have a meal with some of the service users. Staff ate with the service users and appropriate support was given. Food stocks in the home were plentiful and varied with fresh fruit available. Menus were provided with the pre inspection questionnaire. The meals on offer were observed to be varied, nutritious and alternatives were available. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 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 Service users generally receive appropriate personal support but not all had mobility assessments completed. The health needs of service users are generally met. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure residents receive the medication they need. EVIDENCE: Guidance and support is given to service users who require assistance with personal hygiene and this is recorded in the care plan. However, for one service user who uses a walking aid outside of the home a mobility assessment was not available, yet this was observed to be available for other service users. Service users are supported to health care appointments and records of these are well maintained within separate consultation forms. There was documented evidence that health care needs were being identified and followed up. Guidance in the event of epileptic seizure was available in one service user file sampled. Weight monitoring records are completed on a monthly basis. At the last inspection the Manager stated that Optimum intended to introduce health action plans. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. No progress on this was evident at this inspection. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 14 The medication administration records (MAR) were sampled for all service users who live at the home. These were observed to be satisfactory. All medication was being acknowledged when received and two people signed when it was administered. The system was very easy to audit and no discrepancies were found. Prescriptions are photocopied with a copy retained and weekly medication audits are completed. Several service users have medication prescribed on an ‘as required’ basis (PRN), as required at the last inspection PRN protocols have been completed to guide staff as to when the medication should be administered. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 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 The home has a satisfactory complaints system with some evidence that service users are listened to. Adult protection practice require improvement to show that service users are being protected from abuse and that their welfare is being promoted. EVIDENCE: The home has a complaints procedure available. The home’s log of complaints indicates that the home has not received any complaints in the last twelve months. The CSCI has not received any recent complaints regarding the home. Service user satisfaction questionnaires are used as a tool for identifying if service users are unhappy about something or have a complaint. Staff training records show that they have received adult protection training. At the last inspection it was identified that a new CRB and POVA check had not been obtained for a new member of staff. A POVA check has now been obtained for this member of staff and a CRB check applied for. The majority of sampled staff records contained evidence of CRB/POVA checks. However for one staff recently transferred to the home from another part of the organisation the CRB was in a different employers name and there was no evidence of a POVA first check. Sampled service user financial records were satisfactory and receipts were available for expenditure. One service user did not have an inventory available for inspection. An up to date inventory is essential to enable the Manager to identify if any belongings go missing. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 16 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, 26, 27, 28 and 30 This home offers a generally comfortable environment but some safety issues need addressing. Improvement is required to ensure adequate systems are in place to control risk of the spread of infection. EVIDENCE: The home is in keeping with the local area and is well placed in terms of accessing transport and local facilities. It is not evident that the premises are safe as there are requirements from the Fire Officer that need to be met, this is detailed in Standard 42. Since the last inspection in April 2005 some improvements to the premises have taken place. Redecoration of the stairway and dining room has been completed making these areas of the home more pleasant. Odour control devices have also been installed in several areas and these give the home a pleasant odour. The Manager stated that several new thermostatic water valves had been installed to ensure water is delivered at a safe temperature. Bedrooms sampled were seen to be personalised and had been decorated to individuals personal preferences. The home has a shower room on the ground floor. A bathroom is located on the first floor, this is very small in size and is not ideally suited to anyone with mobility difficulties. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 17 The organisation is aware that the bathroom may not meet the needs of some of the service users in the longer term. It has been recommended at previous inspections that the organisation investigate the possibility of providing an additional communal area where visitors could meet service users in private or to provide a quiet area for service users. The Manager stated that the provision of a conservatory and extension to the laundry area were under consideration with the Landlord of the property. Infection control and cleanliness of the home need improvement. One extractor fan was very clogged with dirt and fluff. The Manager will need to ensure the cleaning of extractor fans is added to the cleaning schedule. Requirements were made at the last inspection for the home to comply with requirements from the Environmental Health Officers visit. It remains outstanding to repair the handles to the fridge/ freezer. The Manager said that the handles were not available and so a new fridge/freezer was required. However the Manager does not have a budget to purchase such items and is awaiting permission from Optimum for this purchase. It was identified at the last inspection that the Manager has no devolved budget for the environment. The delay in the purchase of a new fridge/freezer again highlights that the provision of a budget should be considered. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 18 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, 35 and 36 Service users are supported by a team of stable and knowledgeable staff. The procedures for recruitment are not always robust and did not provide satisfactory safeguards to offer protection to service users. EVIDENCE: It is commendable that the home has a very stable staff team with no use of agency staff. Most staff have worked at the home for a number of years. Discussion with the Manager indicates that no staff have ceased employment with the home since the last inspection. It was noted that both staff and service users appear comfortable in each other’s company. Staff give support with warmth, friendliness and patience and treat people respectfully. Three staff are generally on duty during day time hours, staffing levels are appropriate to the needs of service users. Staff files sampled all contained application forms, proof of identity, written references and CRB checks. However for one member of staff the CRB was in a different employers name and there was no evidence of a POVA first check. Discussion with staff and the manager and sampling of records evidences that staff have received training to include adult protection, infection control, communication, first aid, healthy eating and fire. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 19 As required at the last inspection some dementia training has taken place with more in-depth training planned for 2006. Staff at the home have either completed or are undertaking an NVQ in care. Staff are given satisfactory levels of supervision to enable them to carry out their role effectively. Throughout the inspection the Manager was observed to be aware of what staff were doing and offer assistance as needed. Regular, staff meetings take place and records are maintained of these meetings. Staff supervision records were sampled. Since the last inspection the format has been improved. Supervision records were well organised with clear action points arising from each session. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 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, 39 and 42 The organisation is making positive efforts to ensure that service user views underpin service development appropriately. Work practices in the Home generally promote and protect service user’ welfare, health and safety but attention is required to fire and electrical safety. EVIDENCE: The Manager has extensive experience in various aspects of social care. Discussions with the manager demonstrated that she has a good overview of all aspects of the management and smooth running of the home. The Manager stated that she had recently completed the Registered Managers Award and was now enrolling on the NVQ level 4. Throughout the inspection the manager presented as open, co-operative and welcomed constructive feedback. Copies of reports of the visits to the home by the representative of the director of the organisation are now being forwarded to the CSCI. These reports are detailed and cover all areas of the running of the home with clear action points. Systems are in place to seek the views of service users and relatives. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 21 The Manager has also recently audited the number of accidents in the home, identifying possible reasons for any peaks and troughs. Some areas of Health and safety at the home are of concern. The electrical hard wiring certificate for the home recorded that the installation was unsatisfactory and detailed several areas that required attention. The Manager seemed unaware of this and was unsure if any remedial action had been taken. An immediate requirement was made for proposals to be sent to the CSCI regarding the work required. The West Midlands Fire Officer visited the home on 30th September and made several requirements to include attention to fire resisting doors, fire detection required in the laundry and corridor and the front door should not be locked by means of a key. The Fire Officer has stated that some of the requirements are outstanding from previous visits, however the Manager stated she had no knowledge of this as the previous visits were prior to her commencing work in the home. The WMFS have required that proposals to meet these requirements are submitted by 24th October. In the meantime the Manager has installed battery operated smoke detectors and work has been carried out on fire resisting doors. In-house checks on the fire equipment, emergency lighting and fire drills had been completed appropriately. There was evidence on site of the servicing of all equipment. COSHH substances were stored securely and not a risk to residents. The premises risk assessments had been further developed to include the security of the building. Since a break in at the home extra locks have been installed to windows. Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 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 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 3 x 2 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 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pershore Rd (339) Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 1 x E54 S16885 PershoreRd339 V248374 181005 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. 2. Standard 18 19 Regulation 12(1) 12(1)(a) 15 13(6) & 19 12(1) 13(6) & Schedule 4 (9,10) 16(2)(j) & 23(2)(d) Requirement Ensure mobility assessments are completed and available for all service users. The Manager needs to consider how health action plans can be introduced in line with the Valuing People white paper. Staff must have a new CRB /POVA check before commencing work in the home. (Outstanding from 15/5/05) All service users must have an up to date inventory of personal possessions. All the recommendations recorded in the report from the recent visit from the Environmental Health Officer must be actioned- re fridge freezer. (Outstanding requirement from 30/5/05) Ensure the cleaning of extractor fans is added to the homes cleaning schedule. Proposals to meet the requirements from last electrical hard wiring test to be forwarded to the CSCI or evidence that work already completed to be forwarded. Timescale for action 30/11/05 30/12/05 3. 23 and 34 15/11/05 4. 23 15/12/05 5. 30 1/11/05 6. 7. 30 42 23(2)(d) 13(4) 30/11/05 1/11/05 Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 24 8. 42 13(4) & 23 Proposals to meet the requirements from the West Midlands Fire Officer to be submitted to the CSCI. 24/10/05 9. 10. 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 2 Good Practice Recommendations It is recommended that the admission and referral policy is expanded to include how the views of current service users will be taken into account before a prospective service user moves in to the home. Optimum Care should consider giving the manager a devolved budget for expenditure on minor repairs and redecoration of the home. 2. 24 Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 25 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 Pershore Rd (339) E54 S16885 PershoreRd339 V248374 181005 Stage 4.doc Version 1.40 Page 26 - 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!