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Inspection on 19/04/05 for 339 Pershore Road

Also see our care home review for 339 Pershore Road for more information

This inspection was carried out on 19th April 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This is a home with friendly relationships between staff and service users. It has a competent staff team who are knowledgeable about the people they care for. Staff at the home undertake training on a regular basis. The manager of the home has clear ideas on how the home can be further improved and has plans in place to make the improvements happen. Meals served at the home are at flexible times with a choice of food available depending on the personal preferences of service users. The home had had no complaints since the last inspection.

What has improved since the last inspection?

Care plans have been further developed to make them more accessible to service users. Systems for consultation with service users have been further developed, although some of this is still in early stages of implementation. Some improvement to the environment has taken place, the hallway is being redecorated and a new dresser has been installed in the lounge. This makes the lounge more `homely` and welcoming in appearance. Medication systems have improved and the home is now close to meeting the required standard. The majority of staff have now received training in adult protection, this will contribute to service users being protected from the risk of abuse.

What the care home could do better:

Information in the care plan for behaviour management needs to improve to ensure staff consistency in meeting service users needs. Risk assessments needed to be improved to ensure any risks service users may have are reduced as much as possible. Some of the home`s recording systems for weight monitoring, finances and participation in activities need to improve. Systems for the administration of medication that is given `as required` need to improve to ensure staff are clear when it should be given to service users. The organisation needs to review the systems in place for repairs and redecoration to the premises to ensure repairs are not delayed and care staff are not spending valuable time redecorating. The home must ensure that recommendations of the Environmental Health Officer are acted upon. Staff needed to be recruited properly making sure all the right checks had been undertaken before they were allowed to work in the home so that people living in the home were protected. The organisation needs to ensure visits are made to the home by its representative on a monthly basis to ensure it is being managed effectively and the organisation have an overview of the service.

CARE HOME ADULTS 18-65 Pershore Road, 339 Edgbaston Birmingham West Midlands B5 7RY Lead Inspector Kerry Coulter Unannounced 19th April 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. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Pershore Road, 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) 0121 4720224 0121 472 0224 N/A Optimum Care Services Dee Hazle Care Home 6 Category(ies) of Learning Disability (6) registration, with number of places Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. 2. That Desmin Hazle completes the Registered Manager 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 ammended to reflect the age of service users accommodated. Date of last inspection 22nd September 2004 Brief Description of the Service: The home is registered to provide personal care and accommodation for up to six adults who have a learning disability. All of the service users at the home are male. It is a detached building situated on a main road, 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. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out over four and half hours in April 2005. This was the first of the statutory inspections for this home for 2005/2006. During the inspection a tour of the premises was made, two service user and one staff files were inspected as well as other care and health and safety records. The inspector spoke with the manager and two members of staff as well as all five of the service users. However, service users do not have verbal communication and their ability to communicate to the inspector their views of the home was limited. The inspector therefore spent part of the inspection observing care practice. What the service does well: This is a home with friendly relationships between staff and service users. It has a competent staff team who are knowledgeable about the people they care for. Staff at the home undertake training on a regular basis. The manager of the home has clear ideas on how the home can be further improved and has plans in place to make the improvements happen. Meals served at the home are at flexible times with a choice of food available depending on the personal preferences of service users. The home had had no complaints since the last inspection. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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 Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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) 5 Service users have an individual contract but improvement is required to evidence it has been fully explained to the individual or their representative. EVIDENCE: The inspector sampled the contract of two service users, these were observed to include the fee and room to be occupied. The contacts appeared to have been signed by both service users yet they are unable to write. The manager clarified that staff had signed the names of the service user on their behalf. This is not satisfactory and must be amended to reflect this. Since the last inspection the manager has written to relatives of service users requesting them to sign the contract on behalf of the service user. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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, 8 and 9 The care plans detailed how the individual needs of the service users were to be met but improvement to behaviour management systems is required. The systems for service user consultation are generally good with a variety of evidence that indicates service users views are sought and acted upon. Strategies for managing risks were generally clearly identified with only minor improvement required to ensure the safety of service users. EVIDENCE: Individual plans of care are available and progress continues to be made to ensure that all aspects of health, personal and social care needs are identified and planned for. Plans sampled were up to date with evidence of recent review. Monthly evaluations were being documented. It is recommended that review meetings take place six monthly to include the service user and other involved individuals such as relatives or advocates. 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. Improvement was observed to be required to behaviour management strategies. One file sampled did not contain clear guidance about pro-active Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 10 and re-active strategies to manage the challenging behaviour of one individual. The plan did contain some limited information regarding this but it was not presented in a clear and informative format. Care plans sampled cross referenced to risk assessments. Sampling of records and discussion with staff and service users indicate that service users rights to make decisions is generally respected. The inspector observed service users being supported to make every day choices such as what to eat, when to have a cup of tea or when to spend time alone in their room. Service users at the home have limited verbal communication, as a result of this service users meetings are not held. The manager stated that service user views are obtained on a 1:1 basis with key-workers. To improve opportunities for service users the manager has designed a service user satisfaction questionnaire that includes pictures. This has so far been completed with one service user. Since the last inspection service users have been provided with individual activity schedules in picture format and ‘listen to me’ pictures to facilitate communication. 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. The majority were satisfactory. However, the meal time risk assessment for one service user did not identify that he often regurgitates his food, as recorded as occurring in his daily notes. The assessment must be expanded to identify the possible risks of regurgitating food and the measures in place to reduce the risk. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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, 14 and 17 There were no rigid rules or routines in the home and service users have opportunities to participate in appropriate activities. Dietary needs of service users are well catered for with a balanced and varied selection of food available. EVIDENCE: Service users have a planned timetable for attendance at activities outside of the home that includes attending college courses. However the records for one service user did not evidence regular participation in activities. The manager stated that this was due to the individual being unwell, however this had not been reflected in the records. Discussion with staff indicates that consultation is underway with service users to decide on a venue for their annual holiday. Staff gave examples of how service users were supported to make a choice from looking at a variety of holiday brochures. One service user was observed to be supported to do some drawing, another was supported to go for a walk after he had signed that was what he wanted to do. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 12 The food records sampled evidenced there was a good variety of meals on offer. Food stocks in the home were good and there was fresh fruit and vegetables available. Service users were observed to be appropriately supported by staff to eat their lunch. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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) 19 and 20 The systems for the administration of medication are generally good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. Systems for ‘as required’ medication require improvement as guidance on administration is not comprehensive. EVIDENCE: 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. During the inspection the manager informed the inspector that due to concerns of weight loss for one service user recent medical checks had been undertaken and food supplements prescribed. The inspector was therefore concerned that the home had not maintained a regular weight record, this had been last completed eight weeks prior to the inspection. The manager stated that weight had been monitored at the GP visit but that the information had not been recorded in error. The manager outlined future plans to introduce health action planning for service users. 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 Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 14 when it was administered. The system was very easy to audit and no discrepancies were found. As required at the last inspection the home has now commenced photocopying prescriptions and introduced weekly medication audits. Several service users have medication prescribed on an ‘as required’ basis (PRN). As required medication (PRN) needs to be underpinned by a protocol. These must be reviewed at least six monthly. The protocol needs to provide clear guidance on when to use the medication. Two service users attended medication reviews on the morning of the inspection. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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) 23 Arrangements for protecting service users are not satisfactory placing them at possible risk of harm or abuse. EVIDENCE: The organisation has an adult protection policy, this was not sampled at this inspection. As required at the previous inspection, training has taken place for staff in adult protection and abuse. A new CRB and POVA check had not been obtained for a new member of staff. Discussion with the manager indicated that she was unclear about the recent changes that now required all new staff to have a new CRB/POVA check. The manager stated she had not received clear guidance regarding this from Optimum. Financial records pertaining to one service user were sampled. Receipts were available for all expenditures. Initially the money in the wallet did not match the record and there was a shortfall. Investigation by the manager revealed that a member of staff had change from the taxi that had yet to be transferred to the wallet. Where staff are holding monies on behalf of the service user a note to this effect should be available in the wallet. It is good practice that the home counts all service users monies at each handover and maintain a record of this. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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, 28,29 and 30 This home offers a generally comfortable environment but needs to improve the standard of décor in communal areas. Improvement is required to the kitchen area to ensure adequate systems are in place to control risk of the spread of infection. EVIDENCE: The home is kept clean, warm and was free from offensive odours on the day of the inspection. A brief look around the home evidenced that the premises were safe but some communal areas are worn in appearance. The lounge is an area of improvement, a new dresser has made the room more homely and welcoming in appearance. Redecoration of the hallway was underway but progress has been slow as staff are undertaking this task themselves. Discussion with the manager indicates that she has no devolved budget for the environment. An audit of the premises had been completed in January and sent to the provider but some issues remain outstanding. This includes the requirements made at a visit by the Environmental Health Officer to repair the handles to the fridge/ freezer and repair the paintwork above the tiles in the kitchen. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 17 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. The organisation is aware that the bathroom may not meet the needs of some of the service users in the longer term. With this in mind the manager has recently had input from an Occupational Therapist and new grab rails and a bath seat have been obtained. It was recommended at previous inspection visits 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 funding for a conservatory has now been agreed. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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 and 35 Service users are supported by a team of stable and knowledgeable staff. Further training is required in dementia to ensure staff continue to meet the needs of one individual. The procedures for recruitment were not robust and did not provide the safeguards to offer protection to people living in the home. 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. The home provides a minimum of two staff on duty during the day, but it is usual for three staff to be on duty. At night the home provides one waking and one sleep in staff. As required at the last inspection the manager has ensured shift times are recorded on the staff rota. The manager stated that staffing levels in the home will be remain the same when one service user leaves the home. Staff were observed interacting with service users and displayed a good understanding of the service users support needs. The recruitment records for one staff employed since the last inspection were inspected. This indicated that not all the necessary checks had been undertaken prior to employment to ensure the protection of the service users. A criminal records bureau check was available but this was old and there had Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 19 been no new criminal records bureau check or POVA first check undertaken prior to the member of staff commencing work in the home. Discussion with staff and the manager and sampling of records evidences that staff have received training in adult protection, infection control and communication since the last inspection. Staff at the home are also all in the process of undertaking an NVQ. A completed induction record was available for one member of staff, the manager was advised to assess the contents of the induction to ensure it was in line with the TOPPS induction. One service user at the home has dementia, staff have not received training in this area, this must be arranged to ensure staff have an understanding of dementia and are able to meet the needs of the individual. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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) 42 and 43 The manager has a good understanding of the areas in which the home needs to improve. Systems are in place to ensure the health and safety of service users but require review following a break in at the home. 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 evidenced during discussions her knowledge of the needs of the service users in her care. The manager has recently completed her NVQ 4 and is awaiting certification. Health and safety at the home were generally well managed. Staff had received updated training in fire procedures. 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 Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 21 premises risk assessments had been further developed however it did not detail all the risks in the home and how they were minimised. Recently the home had been broken into and the intruder had taken keys and stolen a vehicle. Since this occurrence a lock smith has visited and made alterations to two window locks. However, the manager needs to complete a full assessment of the security of the building. This should include all windows, doors and issues such as adequate external lighting and storage of keys and valuables. At the time of the visit the home’s certificate of public liability insurance had expired at the end of March. The manager stated that the new certificate was in the possession of the Director of the organisation. The inspector was disappointed that there was no evidence of the statutory monthly reports being completed by the representative of the organisation to evidence they are overseeing the running of the home and ensuring the health and welfare of the residents. This concern has been raised in previous reports, it is totally unsatisfactory that no reports were available from August 2004. Visits must occur monthly and a copy of the report forwarded to the CSCI. Failure to comply will result in the CSCI considering enforcement action. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 2 3 2 Standard No 11 12 13 14 15 16 17 x 2 x 3 x x 3 Standard No 31 32 33 34 35 36 Score x x 3 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pershore Road, 339 Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 2 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 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 5 Regulation 12 Requirement The manager must ensure that the service user contracts do not give the impression that they have been signed by service users when this is not the case. Clear guidance about pro-active and re-active strategies to manage any challenging behaviour must be available in service user files. (Previous requirement, timescale of 15/10/04) All personal risk assessments must include all risks identified and how these are to be minimised: The meal time risk assessment for one service user must be expanded to cover the risks associated with regurgitating food. Staff must record how service users spend their days to evidence their social needs are being met. Service user care records must record the reasoning why planned social activities have not taken place. Where assessed as required, the manager must ensure that weight monitoring charts are kept up to date. Timescale for action 30/5/05 2. 6 12 & 15 30/5/05 3. 9 13(4) 24/4/05 4. 12 12(1,2,3) & 16(2)(m) 15/5/05 5. 19 12(1) 15/5/05 Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 24 6. 20 13(2) 7. 8. 23 and 34 23 13(6) 13(6) & 17(2) Schedule 4 (9) 16(2)(j) & 23(2)(d) 9. 30 10. 11. 35 42 18 13(4) As required medication (PRN) needs to be underpinned by a written protocol, specific to the individual service user. The protocol needs to provide clear guidance on when to use the medication. Staff must have a new CRB /POVA check before commencing work in the home. Where staff are holding monies on behalf of the service user a note to this effect should be available in the wallet. All the recommendations recorded in the report from the recent visit from the Environmental Health Officer must be actioned. Staff training in the area of dementia care must be arranged. The manager must ensure a risk assessment of the security of the building is completed following the recent break in at the home. Visits must occur on a monthly basis by the representative of the organisation. A report of the visit must be available in the home and also forwarded to the CSCI. The home must have a copy of up to date employers liability on display. A copy of the certificate must be forwarded to the CSCI. 19/5/05 15/5/05 15/5/05 30/5/05 30/8/05 26/4/05 12. 43 26 30/5/05 13. 43 25(2)(e) 24/4/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 6 Good Practice Recommendations It is recommended that review meetings take place six Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 25 Pershore Road, 339 2. 24 monthly to include the service user and other involved individuals such as relatives or advocates. Optimum Care should consider giving the manager a devolved budget for expenditure on minor repairs and redecoration of the home. Pershore Road, 339 Pershore Road 339 S16885 V221247 190405 Stage 4.doc Version 1.20 Page 26 Commission for Social Care Inspection 1st Floor, Ladywood House 45 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. 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