Inspection on 28/04/05 for 191 Redditch Road

This inspection was carried out on 28th 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.

Other inspections for this house

191 Redditch Road 01/05/07

191 Redditch Road 11/04/06

191 Redditch Road 08/11/05

191 Redditch Road 26/10/04

191 Redditch Road 19/05/04

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Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

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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 Redditch Road, 191 191 Redditch Road Kings Norton Birmingham B38 8RH Lead Inspector Kerry Coulter Unannounced 28 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. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Redditch Road, 191 Address 191 Redditch Road Kings Norton Birmingham B38 8RH 0121 680 2669 0121 680 2669 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) Bourneville Village Trust Maxine Kallon Care Home 5 Category(ies) of Younger Adults, Learning Disability, Physical registration, with number Disability of places Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. 2. That Mrs Kallon completes the Registered Managers Award by June 2005. 3. That she undertakes a minimum of 21 hours dedicated management/administration time a week. 4. That Mrs Kallon attends training on the management of challenging behaviour on a course that is approved by CSCI by September 2005. Date of last inspection 26 October 2004 Brief Description of the Service: 191 Redditch Road is a care home providing personal care and accommodation for five people with a learning disability. Bourneville Village Trust owns the home. The home operates a ‘home for life’ as long as they can adequately meet service users needs, and operates a ‘needs led’ approach, which aims to provide a high quality, residential service. Care is offered with normal lifestyle principles and residents are encouraged to bring personal possessions to the home. All rooms in the dormer bungalow are single occupation, with no rigid visiting hours or set mealtimes. Service users are able to retire and rise when they prefer. They can also shop for, prepare and cook their own meals if they wish, and are offered a choice of leisure time activities geared to their individual needs and abilities. The home is fully equipped with hoists, changing facilities, an Arjo bath, with some bedrooms being fitted with ceiling tracking. The gardens to the front and rear have been designed for wheelchair users. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 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 some of the clients were limited due to their complex needs and limited verbal communication abilities. However, the inspector met with four clients and time was spent observing care practices, interactions and support from staff. A tour of the building and garden was made. Clients 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 manager and several care staff. During this visit the inspector did not have opportunity to speak with relatives and other professionals. What the service does well: The home had a relaxed atmosphere. The home has a group of staff who have worked at the home for a long period of time. They are well motivated; participate in the day-to-day operations of the home whilst maintaining a clear sense of direction. Observations revealed positive relationships between staff and clients even though some clients have severe communication difficulties. A number of people are encouraged and supported in going on holiday and are consulted regarding the location. A wide range of activities are on offer, in line with individual client needs. Care plans and relevant documentation are comprehensive, regularly reviewed and up dated when changes occur. The medication system is well managed. Staff at the home seek input from other health and social care professional to assist in meeting individual need. The standard of the environment within this home is good providing clients with an attractive and homely place to live. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 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. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 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 Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 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) 1 The Statement of Purpose and Service User Guide provide prospective service users with most of the relevant information about the home to enable them to make an informed choice about if they want to live there. EVIDENCE: The home has further developed the statement of purpose since the last inspection. The complaints section now includes details of the CSCI and is clear that CSCI can be contacted at any point with a complaint. The home will also need to consider how the service user guide can be made more accessible to clients living at the home, some of whom have a sensory impairment as well as learning disabilities. However, the manager has managed to obtain a sample service user guide from which she intends to develop the guide for Redditch Road. Consideration should be given to the use of pictures, video or audio as suitable to individual need. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 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 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. The systems for service user consultation are generally good. Strategies for managing risks were generally clearly identified with only minor improvement required to ensure risk is effectively managed. EVIDENCE: Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 10 The home has a service user plan for each individual, which includes detailed profiles, activity plans, and daily recording. In addition, some service users have individual support strategies and guidelines, in some cases devised by professionals working in partnership with staff in the home. Two service users plans were examined, and these were found to contain appropriate detail. In addition the home has cross-referenced these plans to risk assessments for individual service users. Risks had been identified, assessed and regularly reviewed. Generally risks were found to be well managed. Where one serious risk to a client had been identified the manager had written detailed guidelines and also made a referral to the Social Worker to discuss areas of concern. However, further work is required to reduce the risk to one client and staff when crossing roads. The manager was advised to consider route planning and evaluation of incidents. Service users are encouraged as far as possible to make decisions about their lives, this is done through regular client meetings, attendance at reviews and 1:1 consultation. It is an area of good practice that one client has a care plan in a picture and word format whilst for another client who has a visual impairment, staff had read the care plan to him. Conversation with two clients evidenced that they had been involved in the decision regarding the colour scheme of planned bedroom redecorations. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 16 and 17 The home actively encourages and supports individuals in developing social skills and in continuing their educational needs and preferences. Intergration within the community and pursuit of leisure activities are integral elements of the ethos of the home. Meals are both well managed, creative and provide daily variation. EVIDENCE: Sampling of client records and observation of practice indicate that clients undertake a wide range of activities, to include in house, day centres and in the community. On the day of the inspection one client had arrived home from a holiday in America. She had been supported by two staff and satisfactory risk assessments had been completed prior to departure. Discussion with the client indicated she had enjoyed the holiday and was already thinking about where she would like to go for her next holiday. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 12 Activities taking place on the day of the inspection included two clients being supported to look at communication picture cards and several clients went to snoozelum in the afternoon. Since the last inspection the manager has introduced a tool for monitoring the level and variety of activities offered to clients. Although still in its early stages, this will provide a good system for evaluating if the home is meeting individual care plans with regards to activities. Only one client ate a meal whilst the inspector was in the home. This was observed to be sandwiches and was offered more as a snack as she had arrived home from a long plane flight from America. The individual was quite tired and so chose to eat in the lounge area rather than at the dining table. The manager stated that the menu is completed on a weekly basis with input from all clients. The menu indicated that a varied and balanced diet is provided. Healthy eating is encouraged and fresh fruit is readily available. The menu and other documentation revealed that a number of options are offered. The manager stated that clients are offered the opportunity to participate in food shopping. There was no evidence of strict house rules. Staff were observed sitting and socialising with individuals. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 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, 20, 21 The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: Care plans indicated the degree of assistance required, this varied form very little such as prompting to full personal support. At the last inspection the inspector observed the bathroom door was left slightly ajar whilst a service user was being assisted. The manager confirmed that this practice has now ceased, however the Adult Protection Policy needs amendment to reflect this (see Standard 23). Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 14 There is evidence of service users receiving comprehensive health checks and monitoring, and detailed records are maintained. The home has received support from a community nurse, in managing some aspects of individual behaviour. A consultant is involved with one service user who has been diagnosed as in the early stages of dementia/Alzheimer’s disease. It was recommended previously that Health Action Plans should be implemented. The manager stated that she had obtained sample formats for this but that Bourneville Village Trust was still deliberating on their introduction. The systems for the safe storage, handling and administration of medication were well managed. The home retains copies of prescriptions, and audits are undertaken for all PRN (as required) medication. No errors were noted, and the inspector was advised that all staff have completed accredited medication training. Medication audits are completed weekly, this is an area of good practice. The accident book was not sampled at this inspection and will be examined at the next visit. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 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 The complaints system in the home is satisfactory. The arrangements in place to protect clients from the possible risk of harm or abuse are not satisfactory and require improvement. EVIDENCE: The homes policy and procedure for dealing with complaints was not examined as it had been observed to meet the required standard at the inspection in June 2004. As required, the home has now introduced a log to record any complaints received and detail action taken. Bourneville Village Trust have previously consulted with the CSCI regarding their adult protection procedures. However, they will need some amendment as the policy instructs staff to leave the door ajar when assisting clients to bathe. The policy must ensure that service users privacy is maintained whilst bathing. To this end it should detail that the bathroom door must remain closed unless an assessment of risk identifies the need for the door to be left ajar. It has previously been required that the policy of physical intervention is developed, in line with codes of professional practice. Bourneville Village Trust has not yet developed a new policy. This is of concern as it has been a requirement of two previous inspections. Evidence was not available that all the necessary checks had been completed for the recruitment of a new member of staff (see standard 34). Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 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 The standard of the environment within this home is good providing clients with an attractive and homely place to live and meeting their needs. EVIDENCE: The home was seen to be well maintained, comfortable, and free from odour. Furniture, fixtures and fittings were of a good standard and well maintained. The access to laundry is not possible for most clients, and this has been documented within the statement of purpose. The laundry does not have a wash hand basin, consideration should be given to installing one. This would improve the arrangements for infection control. The home has a pleasant rear garden, accessed through the lounge. Access to the kitchen for clients is good and worktops are of differing heights to meet client need. The bedrooms viewed were clean and tidy and personalised to the extent of the occupant’s wishes. All rooms had suited locks with keys available to the client. One bedroom has a range of sensory equipment. One client expressed their satisfaction with their rooms and the personal possessions. Communal living space does meet minimum requirements. The inspector was advised that the Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 17 home is to be re-decorated in the forthcoming financial year and evidence of consultation with clients was available. The home has a specialised bathroom with Arjo bath and aids and adaptations, and a separate level access shower facility, which appear to suit the needs of clients currently accommodated. The number and location of facilities appears suitable to current clients. In the kitchen hygienic methods were noted to be being deployed. The inspector observed that a cleaning schedule was in place, fridge/freezer temperatures were being recorded and all foods were appropriately stored. A recent inspection of the home by the Environmental Health Inspector had a positive report, the one requirement had been actioned. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 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) 36 33, 34, 35 and The staff team offer consistency of care and have a good understanding of client needs. The current arrangements fail to provide evidence of a robust recruitment procedure, and therefore fail to safeguard clients. EVIDENCE: There are male clients at the home but there are no male staff employed. Consideration should be given to recruiting male staff to reflect the gender composition of the home. The home continues to operate at three staff per shift, which appears adequate to meet the needs of current clients. One night waking and a sleep in member of staff are on duty at night. As previously required the staff rota now clearly denotes the manager’s hours which are to be utilised purely in management task. However observation of the minutes of staff meetings and discussion with staff indicate that the rota’s are produced at the organisations headquarters thereby reducing the autonomy of the home manager to complete the rotas with client need as the focal point. Consideration must be given to the manager having the opportunity to complete the staff rota rather than it being completed externally to the home. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 19 Staff have received a variety of training and the home is commended for the high percentage of staff who have achieved an NVQ in care. Evidence was observed of staff completing medication, dementia, first aid, food hygiene and adult protection training. Staff had received fire training in the last twelve months but this must be updated six monthly. However, it is of concern that staff have not had training in physical intervention. This has been a requirement of two previous inspections. Notifications received from the home do indicate that some clients may display behaviours that can be challenging. Additionally, discussion with the manager indicates that physical intervention may be needed when assisting one client to cross the road to protect them from significant harm. The supervision records for two members of staff were sampled. The home has adopted a formal structure for these supervisions sessions, and those examined provided evidence of a good support process for the staff and management of the home. The recruitment records for two staff were sampled. One contained all the necessary information, but the file for one new staff was very limited with no evidence of Criminal Record Bureau (CRB) checks, proof of identity, written references and an application form. The manager stated all the documentation was at headquarters but managed to obtain a fax to evidence a CRB had been obtained. It is essential that the required recruitment information is available in the home so that it can be evidenced that recruitment procedures protect the clients. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 42 and 43 The manager has a good understanding of the areas in which the home needs to improve but needs support from the organisation to ensure this happens. Satisfactory systems are in place to ensure the health and safety of service users. EVIDENCE: The manager has recently been successful in undergoing the process to become the registered manager of the home. One member of staff said that she received appropriate support from the manager. Regular supervision and meetings take place to enable staff and service users to air their views. Health and safety at the home was well managed. 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 to include hoists. COSHH substances were stored securely and not a risk to Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 21 residents. The manager also completes a health and safety audit but this was not sampled at this inspection. There was no evidence of the statutory reports being completed by the representative of the organisation on a monthly basis to evidence they are overseeing the running of the home and ensuring the health and welfare of the residents. For the last eight months only two reports were available. Visits must occur monthly and a copy of the report forwarded to the CSCI. It is noticeable that the many of the requirements require action from Bourneville Village Trust to ensure they are actioned, rather than the home manager. These requirements include issues of policy and funding for training. Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Redditch Road, 191 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 2 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 17(2) Schedule 4(2) Requirement Service users guide must include· Summary of statement of purpose· Terms and conditions in respect of accommodation to be provided, including amount and method of payment· Standard form of contract· Most recent inspection report· Summary of complaints· Guide to be given to each client in an appropriate format. (Outstanding from inspection of January 2004) Further work is required to manage the risk to one client when crossing roads. The adult protection procedures l need amendment as the policy instructs staff to leave the door ajar when assisting clients to bathe. The policy must ensure that service users privacy is maintained whilst bathing. To this end it should detail that the bathroom door must remain closed unless an assessment of risk identifies the need for the door to be left ajar. The home must have a written policy on physical intervention, which must be in line with codes Timescale for action 30/6/05 2. 3. 9 23 13(4) 12(1) 13(4) 28/5/05 30/6/05 4. 23 13(7) & (8) 30/6/05 Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 24 5. 33 18(1) 6. 34 13(6) 19 7. 35 13(6,7,8) 18 (1) 8. 43 26 of professional practice, recognised by relevant professionals. (Outstanding from inspection of January 2004) Consideration must be given to the manager having the opportunity to complete the staff rota rather than it being completed externally to the home. The home must have available all the staff recruitment records specified in regulation 19 so that it can be evidenced that recruitment procedures protect the clients. Training is required for all staff in:(a) Physical Intervention (b) Fire training, six monthly. (A. Outstanding from inspection of January 2004) Evidence of the statutory reports being completed by the representative of the organisation on a monthly basis to evidence they are overseeing the running of the home must be available. Visits must occur monthly and a copy of the report forwarded to the CSCI 30/5/05 30/5/05 30/6/05 & 30/5/05 30/5/05 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 19 Good Practice Recommendations The inspector recommends that the home develop Health Action Plans for service users A Health Action Plan is a personal plan about what a person with learning disabilities can do to be healthy. It lists any help people might need to do those things. It helps to make sure people get the services and support they need to be healthy. The laundry does not have a wash hand basin, E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 25 2. 29 Redditch Road, 191 3. 4. 33 39 consideration should be given to installing one. This would improve the arrangements for infection control. Consideration should be given to recruiting male staff to reflect the gender composition of the home. The needs to have a continuous self monitoring system, using an objective, systematically obtained, reviewed, and verifiable method - (Quality assurance system) which involves service users. An internal audit should take place at least annually. (Carried forward from previous inspection) Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Redditch Road, 191 E54 S16959 Redditch Road 191 V224535 280405 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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